Briones, Hugo Barco NEW YORK CITY THE CITY OF NEW YORK—DEPAA'fI&Tr_ F HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE
May 04, 2020 09:51 PM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-20-040705
EVENT:(CHECK ONLY ONE) X DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION """"""""""""'""""""""""""'""""""""""""'"""""""-""""_"""_"""_
CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (YYYY)
Hugo Barco briones 84 ]Male EVENT 05 01 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW PORK CITY
Queens Rego Park Healthcare
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD U INTERMENT 'X CREMATION
OF ME/MLI Cheryl Luning
Bhaskar R Yeturu DISPOSAL U OTHER M.E.CASE#Q20041068
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
{YYYY)
DISPOSITION 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 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 c/�tc aeG c/�itG Sil—r. roN allyAulhanfi—d 14105
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE t� UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department � •� '�'�*�•
of Health and Mental Hygiene;or if it has been corrected, 0 &--
i
interlined or altered in any manner. i Cly glal"df
• •
VR 21(REV.7/09) FEE PAID$40.00 DATE 05 / 04 /2020 0 , By SeryiGe_Evital
MM DD YYYY Cyr Nay t
Public Health Law Sec. 4145(2b) - 7 (f
Receipt
Human remains of delivered on , 20
Pine View Cemetery amed on burial permit
Official se# ` � 1