Gutierrez, Gilberto 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 01,2020 10:01 AM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
EVENT:(CHECK ONLY ONE) M DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION 156-20-038865
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CERTIFICATE NUMBER
NAME First,Middle,Last AGE :Male]
DATE [MONTH DAY YEAR
OF (YYYY)
Gilberto Gutierrez 85 EVENT 04 25 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Bronx BronxCare Health Systems
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER :' CERTIFIER METHOD ❑ INTERMENT X CREMATION CREMATION APPROVED BY
OF ME/MLI Zhanna Geor ievskaya
Sudiksha Regmi DISPOSAL ❑ OTHER M.E.CASE u B20024480
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
DISPOSITION OF (YYYY)
w Pine View Crematory Queensbury, NY DISPOSITION 05 01 2020
i%glbERTIFICATE 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.
NAME OF ESTABLISHMENT ADDRESS CITY AND STATE
__j
FUNERAL N.Y.STATE REG.#
ESTABLISHMENT Sist eral Home, Inc. 3489 E Tremont Ave Bronx NY 01601
APPLICANT NAME OFN.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
John J. Sisto 13334
Signa�ure Elearonically Authantlra�eo
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department °:' '�� L�
of Health and Mental Hygiene;or if it has been corrected, :'
interlined or altered in any manner.: Cry Registrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 04 / 27 (2020 *00 By Service Evital
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MM DD YYYY fio eOF o"y
Vas
Public Health Law Sec. 4145(2b)� p 1 ' �(
Receipt
Human remains of delivered on j J, 2
4
Pme'View Cemetery Representing the funeral home named on bur
Official Funeral Directors Reg.or License#