Jackson, Andrea NEW YORK CITY THE CITY OF NEW YORK—DEPARTWNT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
April 13,2020 09:09 PM 1.5&20-025733
EVENT:(CHECK ONLY ONE) ®DEATH El SPONTANEOUS TERMINATION O INDUCED TERMINATION �— TE NUMBER --
NAME First,Middle,Last AGE SEX pOTE MONTH DAY YEA,RI
Andrea Jackson 78 Female EVENT 04 13 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NE1M PORK CITY
Manhattan New YorkPresWeiian Hospital
CERTIFIER NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT 31 CREMATION CREMAl l F"OVED BY:
OF ME/MLI .Y6t tfy Stuelpnagel
Richard Greendyk DISPOSAL ❑ OTHER M.E.c, a M20034231
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STAVE DATE MONTH DAY YEAR
OF (YYwI
DISPOSITION Pineview Crematorium Quennsbury, New York DISPOSITION 105 09 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.
NAME OF ESTABLISHMENT ADDRESS CITY AND STATE N.Y.STATE REG.#
FUNERAL
ESTABLISHMENT Hood Funeral Services Inc. 2601 Pitkin Ave Brooklyn NY 02064
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
Kenneth Hood EwdruNceiyx&wucff,ea 11651
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
a •! �•
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. ze r 0 Cry R8QI5ttaC
•
VR21(REV.7/09) FEE PAID$ 40.00 DATE 04 / 15 /2020 00. .00 00 By John Lee _
MM DD YY �'DF'VE`U"
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Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
r
Pine View'Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#