Farres, Lumen NEW YORK CITY THE CITY OF NEW YORK—DE0A6VeNT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OP-VITAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
May 05, 2020 1216 PM 156-20-040909
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE I SEX DATE MONTH DAY YEAR
OF (YYYY)
Lumen Farres 101 Female EVENT 05 03 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW PORK CITY
EVENT Queens New York-Presbyterian Queens
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION
CREMATION APPROVED BY:
�
OF ME/MLI Adrienne Licking
Zikran Choudhury DISPOSAL ❑ OTHER M.E.CASE# Q20041093
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
OF (YYYY)
DISPOSITION Pine View CrematoryQueensbu NY DISPOSITION
ry, 05 08 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.Y.STATE REG.#
ESTABLISHMENT Fox Funeral Home, Inc. 1 9807 Ascan Ave Forest Hills NY 00603
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGN
AT
'U
URRE ��p/y N.Y.STATE LIC.#
Steven Duca 0 fG " Signature Electronically Authenticated 14007
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE QUESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department ��• �� .
of Health and Mental Hygiene;or if it has been corrected, :
interlined or altered in any manner. V. '
�• • City Registrar
VR21(REV.7/09) FEE PAID$40.00 DATE 05 ) 03 i2020 *0.** ,a,** By Service_Evital
MM DD YYYY 4/yNON
Public Health Law Sec. 4145(2b) 013 1-
Receipt
Human remains of delivered on , 20—
�M
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# w