Kearney, Jamal i
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 09,2020 10:09 AM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-20-021455
EVENT:(CHECK ONLY ONE) M DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION ------------cERTiFicnTe NiiMaeR
NAME First,Middle,Last AGE I SEX I DATE MONTH DAY YEAR
OF (YYYY)
Jamal Kearney 38 Male EVENT 104 07 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Bronx 1604 University Ave, Apt 21, Bronx, NY 10453-6978
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD ❑ INTERMENT CREMATION OF ME/MLI Joseph Pestaner
Amanda Krausert DISPOSAL ❑ OTHER M.E.CASE#B20013737
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DOTE MONTH DAY YEAR
)
DISPOSITION Pine View Crematory Queensbury, NY I DISPOSITION 105 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 519naWmEbctro RyAahenUctetl 14105
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, �
• ` i „A� -'
interlined or altered in any manner. ze ' Cry Registrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 04 ) 27 )2020 00 , By Service Evital
MM DD YYYY OF NEY
Public Health Law Sec. 4145(2b) 013714
{
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on b•
Official Funeral Directors Reg.or License# `