Adhikary, Gita R. 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 04,202012:06 PM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-20-040341
EVENT:(CHECK ONLY ONE) M DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION
CERTIFICATE NUMBER
NAME First,Middle,Last AGE I SEX I DATE I MONTH DAY YEAR
OF (YYYY)
Gita R Adhikary 70 Female EVENT 04 30 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
Queens 9729 84th St, Ozone Park, NY 11416-2006
CERTIFIER NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT X CREMATION CREMATION APPROVED BY:
OF ME/MLI Terra Cederroth
Terra Cederroth DISPOSAL ❑ OTHER M.E.CASE#Q20038979
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
(YYYY)
OF
DISPOSITION Pine View Crematory Queensbury, CT 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 New Leaf Cremation 3930 Long Beach Rd Island Park NY 02058
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
Michael Noll SignriureElecV—KyAug nfiwledl 14105
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
of •!e •.•
NOTICE: This permit is not valid without the seal of the Department ���•,�-� t,,:� n� r
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
( I DATE 05 / 02 /2020 96 , �.�,' By Service_Evital
MM DD YYYY Cyn NEtyV
3
Public Health Law Sec. 4145(2b) Q 1 3 7 1_8
Receipt
Human remains of ? ` 5 `` delivered on , 20
l
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
i