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Simms, Jimmy 1'511� NEW YORK CITY THE CITY OF NEW YORK-DEPARTMENT OF HEALTH AND MENTAL HYGIENE DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS AND MENTAL HYGIENE April 30,2020 01:35 PM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS 156-20-038415 EVENT:(CHECK ONLY ONE) X DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION -----------cERriFicaTe NiiMeeR NAME First,Middle,Last AGE I SEX I DATE MONTH DAY (YEAR OF Jimmy Simms 77 Male EVENT 104 13 2020 BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS PLACE OF NEW PORK CITY EVENT Brooklyn New York Presbyterian Brooklyn Methodist Hospital NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY: CERTIFIER METOFOD ❑ INTERMENT CREMATION ME/MLI Donna MarieM La Bella Tiffany Kuo DISPOSAL ❑ OTHER M.E.CASE#K20036725 PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DOT Y E MONTH DAY YEAR DISPOSITION Pineview Crematory Queensbury, New York DISPOSmON 05 01 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 D'Arienzo Funeral Home, Inc. 104 Skillman Ave Brooklyn NY 00407 NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.# APPLICANT �o© C � L John O D1 Arienzo ry 10843 PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE. NOTICE: This permit is not valid without the seal of the Department a��,,• �• ti • �! r001. Y of Health and Mental Hygiene;or if it has been corrected, �'• '�•� 40J/ ' , interlined or altered in any manner. City Registrar VR 21 (REV.7/09) FEE PAID$40.00 DATE 04 ) 29 )2020 ' ••���•• By Serv_ice_Evital MM DO YYYY 4ryOFNEvt� Public Health Law Sec. 4145(2b) 4 0 Receipt Human remains of delivered on ' , 20 f. Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#