Little, David { # 711
NEW YORK CITY THE CITY OF NEW YORK i DEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
OCTOBER 20,2017 01:19 PM 156-17-042631
EVENT:(CHECK ONLY ONE) ®DEATH 0 SPONTANEOUS TERMINATION 0 INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY Y YY)
YEAR
OF
David L Little 63 Male EVENT 10 18 2017
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Manhattan Memorial Sloan-Kettering Cancer Center
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD ❑ INTERMENT XI CREMATION
OF ME/MLI
Hannah Roberts DISPOSAL ❑ OTHER M.E.CASE# M17023313
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DAATE MONTH DAY YEAR
)
DISPOSITION Pine View Crematory Queensbury, NY DISPOSITION 10 26 2017
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 Hawthorne Funeral Home 21 W Stevens Avenue Hawthorne, New York 00760
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
APPLICANT
Ernest J. Carpentieri ��n� a t�e���natureEl Electronically ,ca 10553
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE R EOUES " 'BOVE.
NOTICE: This permit is not valid without the seal of the Department ti°f•'.• �•i�. 4I ( ) (P 4 JI 14
of Health and Mental Hygiene;or if it has been corrected, *'• 4'•s I�
interlined or altered in any manner. so;" ;R�'', 0g City Registrar
0.VR21(REV.7/09) FEE PAID$ 40.00 DATE 10 / 20 /2017 '''' +•, By Eddie Velasquez
MM DD YYY' -