Dixon, Theodore / NEW YORK CITY THE CITY OF NEW YORK—DEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE
May 04,2020 10:21 PM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-20-040714
EVENT:(CHECK ONLY ONE) M DEATH ❑SPONTANEOUS TERMINATION O INDUCED TERMINATION -"......_."RTI-I___.ATE-""UMBE""-------
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CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (YYYY)
Theodore Dixon 79 Male EVENT 04 21 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Bronx Lincoln Medical and Mental Health Center
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL,EXAMINER'S NUMBER METHOD U INTERMENT X CREMATION CREMATION APPROVED BY:
OF MEIMLI Kristin Roman
Gulce Solakoglu DISPOSAL V OTHER M.E.CASE R B20041 081
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
{YYYY)
DISPOSITION Pine View Crematory Queensbury, NY DISPOSITION 05 05 2020
THE CERTIFICATE OF DEATH HAVING BEEN FILED AS REQUIRED BY THE HEALTH CODE,AND ALL LAWS AND REGULATIONS
GOVERNING THE PREPARATION AND DISPOSAL OF HUMAN REMAINS HAVING BEEN COMPLIED WITH, PERMISSION IS
HEREBY REQUESTED TO DISPOSE OF THE REMAINS AS IDENTIFIED ABOVE.
FUNERAL NAME OF ESTABLISHMENT ADDRESS CITY AND STATE N.V.STATE REG.#
ESTABLISHMENT New Leaf Cremation 3930 Long Beach Rd Island Park NY 02058
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
Michael Noll cwux��Cffolr Sig—,El—mcallyANhenfi—a 14105
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
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NOTICE: This permit is not valid without the seal of the Department
of Health and Mental Hygiene;or if it has been corrected, • .x
interlined or altered in any manner. ' I .% Cryistr8f
VR 21(REV.7/09) FEE PAID$40.00 DATE 05 04 /2020 ' sue, By Service_.E_vi_t_al
MM DID YYYY Nvo t
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Public Health Law Sec. 4145(2b)~ 74
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#