Graham, Clarise 6
_ �►�
NEW YORK CITY THE CITY OF NEW YORK—DEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
April 12,2020 04:54 PM _ 1.56-20-024614
EVENT:(CHECK ONLY ONE) N DEATH ❑SPONTANEOUS TERMINATION El INDUCED TERMINATION CERTIRCATE NUMBER
NAME First,Middle,Last AGE I SEX DATE I MONTH DAY Y YYR)
OF
Clarise Graham 55 Female EVENT 04 12 2020
BOROUGH NAME OF HOSPITAL OR INSTRUTIoN OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Queens 4104 12th St Apt 1E Long Island Cdy, NY 11101-6322
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION
CREMATION APPROVED BY:
�
OF MElMLI Kara Storck
Kristin Hord DISPOSAL ❑ OTHER M.E.CASE 8 Q20016593
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
OF (WYY)
DISPOSITION Pineview Crematorium Queensbury, New York DISPosmoN 05 07 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 1. 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 11651
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department ! •'•��';, I/vale of Health and Mental Hygiene;or if it has been Corrected,
interlined or altered in any manner.: delf Cry ReglStrar
VR 21(REV.7ro9) FEE PAID$ 40.00 DATE 04 / 19 /2020 •�. �• By_Service_Evital
MM DD YYYY
Or NN'
Public Health Law Sec. 414-1(2b), f
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#