Willard, Nicollete 1 J"�
NEW YORK CITY THE CITY OF NEW YORK—DEPARTMENT OF HEALTH AND MENTAL HYGIENE N
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
DULY 13,2018 04:29 PM 156-18-029498
EVENT:(CHECK ONLY ONE) N DEATH 0 SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIRCATE NUMBER
First,Middle,Last AGE SEX DATE MONTH DAY YEAR
NAME (YYYY)
OF
Nicollete Willard 23 Female EVENT 07 10 2018
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Bronx Montefiore Medical Center-Henry and Lucy Moses Division
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION CREMATION APPROVED BY:
CERTIFIER OF ME/MU
Kristin Roman DISPOSAL ❑ OTHER M.E.CASE# B18016600
NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
PLACE OF OF
DISPOSITION Pineview Crematory Queensbury, NY DISPOSITION 07 16 2018
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.
NAME OF ESTABLISHMENT ADDRESS CITY AND STATE N.Y,STATE REG.#
FUNERAL
ESTABLISHMENT John F.X. Mckeon &Son, Inc. 3129 Perry Avenue Bronx, New York 00936
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
APPLICANT G7-�/Ga C,2� A
William Curran (/(/ t Signature EIectronica5yAutherncated 10797
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE R . ' .r :EQUES .BOVE.()
NOTICE: This permit is not valid without the seal of the Department .., " "`-�••!� r� f
of Health and Mental Hygiene;or if it has been corrected, • -..`.•
interlined or altered in any manner. . •':,icy' _-,I: : City Registrar
II.VR21(REV.7/09) FEE PAID$40.00 DATE 07 / 13 /2018 .• ",':•o, By Kaniz Fatemah
MM DD YYYY CT,Cc,E*