Marlow, William0912112019 08:27 TAX) R.001 1001
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NEW YORK CITY THE CnY OF NEW YORK-- DEPARTMENT OF HEALTH AND MENTAL HyOtENB
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE
September 21, 2019 09:03 AM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMIAINS 1 56-19-038465
EVENT: (CHECK ONLY ONR) � DEATH C3 5pONTANEOUS TEFIMINA7ION ❑ INDUCED TERNNNATION __ _ ce tmnca rnu KR -
Abe sEx DATE IAaNr11 oAY)
NAME qw. Middle. I�mi
Wilharn Marlow77 Maie ESN' 019 19 2p19
SORtxmm NAME Of MOSMAL OR *WiyWrgI N OR SrMT ADORlSS
PLACE OF NEW YORK CITY
EVENT Brorlx Fieldston Lodge Care Center
yp CrAIMTION App"Fl1 BY:
NAME Oi PR(SJ :IAN OR MEDICAL exaMaJER�s r+u►aaeR is U *nW M 14T p( "ON Mark H�nsbr0 t1
CERTIFIER OF
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018PWL U OTHER_ ,t,E, F+6190 _
Olusegun O untowore MgerrN oAv _ WAR
NAME CF CB1r6TERY OR CIIEMATORY (OR DESI FAA Tx" OIrY OR GCANiTY AN0 STATE DATE
OF
PLACE OF ais sman 09 23 2019
aI6p0611ION Pine View Crematory Queensbury, Now York
TW Cr-ATWICATE OF ()E.ATH HAVMKi B _M r;14CV AS RCOUIRED SY THE HEAITN CODE, AND ALL LAWS AND REOIAA71t?Nt�
GOVERNING THE PREPARATION AND DISPOSAL. OF HUMAN REM"S h AViNO BEEN COMPLIED WITH, PERMIB3 N IS
HEItCCY fP.OUESTE'D TO OWOSE Of THE REMAINS AO IDENTIFIED ABCIVE clrr Aala STATE N.Y. LRATG qLQ• it
NAM6.OF68TABLiSFWEhir AODREBS
FUNEAAL Brooki n NY 00947 _
ESTABtJSHMENT Jurek Park Slope Funeral Horne, Inc 728 4th Ave Y
N.Y. STATE uC. 0
NAIYIE or N.Y. STATE uce"HED M)NERAL.OMECT6R (rlyNTj u"TURE ti
APPLICANT 13469
f:hristooher Stile
PERMISSION IS HEREBY GRANTED TO D*"E OF THE RE BESTED ABOVE. `/� % ► /�
40
NOTICE: TINE psrmk iS n04 valid wltho'�t the seal Or the Clejldr(tiWnt +
01 Mesta rend Menzel Hygiene: of it it has been corrected. i 9r my C
rik Irdewd or mitered In any maruW . 6 0
4>) 00 9 20 2019 ' •e .` By Jerorre Zaltcs
VA 21 (REV. rxa) FEE PAID S .—=-- _--.- DATE _ MM .— no / YYYY • e 0
a�eq�
Public Health Law Sec. 4145(2b)
012552
Receipt
Human remains of 'j- delivered on 20
Pine View cemetery Representing, the funeral home named on burial permit
Official Funeral Directors Reg. or License #
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