Houston,Evelyn 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 01,202011:21 AM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-20-038915
EVENT:(CHECK ONLY ONE) M DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION ----------cEi iiFiciiii NUMsea
NAME First,Middle,Last AGE I SEX I DATE I MONTH DAY YEAR
OF (YYYY)
Evelyn Houston 75 Female EVENT 04 22 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Bronx Lincoln Medical and Mental Health Center
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT X CREMATION �CREMATION APPROVED BY:
OF ME/MLI
Cheryl Luning
Wajahat Khatri DISPOSAL ❑ OTHER M.E.CASE#B20039405
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE I MONTH DAY YEAR
OF (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 1 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 I cwG�oer SlgnaWmEWc NnIyAufl—ficaled 14105
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department =�!�� ��•: yl//�
of Health and Mental Hygiene;or if it has been corrected, 0 s
interlined or altered in an �� +
y manner. ` Cry Registrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 04 ) 30 /2020 %�•� , �. ' By Service
MM DD YYYY �OFNEt��
Public Health Law Se'-A145(2b) Q 1 71 E)
Receipt
Human remains of delivered on , 20
a!%
Pine View Cemetery Representing the funeral home named on bur alpermit
Official Funeral Directors Reg.or License# t