Das, Jhama W
NEW YORK CITY THE CITY OF NEW YORK—DEPARTMENT OF HEALTH AND MENTAL HYGIENE 15 /9
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
May 02,2020 01:01 PM 156-20-039560
EVENT:(CHECK ONLY ONE) IN DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEEAARt l
OF
Jhama Das 79 Female EVENT 04 30 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW PORK CITY
EVENT Queens Long Island Jewish Medical Center
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION CREMATION APPROVED BY:
OF ME/MLI Kara Storck
Sarah Ashour DISPOSAL ❑ OTHER M.E.CASE# Q20039583
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY Y �
DISPOSITION OF ( )
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.Y.STATE REG.#
ESTABLISHMENT Fox Funeral Home, Inc. 1 9807 Ascan Ave Forest Hills NY 00603
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE _ _-- N.Y.-STATE LIC.#
APPLICANTµ (mil ��n/y
Steven Duca C)ft lwa 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, �• •y Y Q��,
interlined or altered in any manner. �i 1 Cry Registrar
�• •�.
VR21(REV.7/09) FEE PAID$ 40.00 DATE 05 / 01 /2020 ••. •� By_Service_Evital
MM DD YYYY �'OFNem$
Public Health Law Sec. 4145(2b) . - e 01 3 7 C O
Receipt
Human remains of delivered on , 20
T i
P4il evS Cemetery Representing the funeral home named on burial permit
official... :',` Funeral Directors Reg.or License#