Boller, Dianne Feb 01 2011 9: 13AM HP LASERJET FRXMCKEON FH 7186556461 page 1
NEW YORK CITY THE CITY OF NEW YOIU(-AEI ARTMENT OF HEALTH AND MENTAL HYGIENE •
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE
FEBRUARY 01,2011 08:11 AM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-11-004610
EVENT:(CHECK ONLY ONE) ®DEATH 0 SPONTANEOUS TERMINATION 0 INDUCED TERMINATION cerMem mown
NAME First.kiddie,LAN - AGE - SEX DATE MONTTf DAYYEAR(YYYh
OF
Dianne Boller 53 Fernal. EVENT ,01 29 2011
BOROUGH - NAME OF HOSPITAL OR INSTTTU ION OR STREET ADDRESS
PLACE OF
NEW YORK CITY
EVENTManhattan The Mount Sinai Hospital
TOME OF PHYSICIAN OR MEDICAL SCAMPERS NUMBER CREMATION APPROVED BY:
CERTIFIERr1lTee0D ❑ warren MI CREMATION {memu Alfred Frederic
Vinh Tung Nguyen DISPOSAL ia MIET ALE.CASES M1100687
PLACE OF NAMEOF CEMETERY OR CREMATORY(OR DESTINATION) cry OR COUNTY AND STATE DATE MONTH DAY (gin
DtBPolSRTCN Pine View Crematory Queensbtry. NY DISPOS$TTDN 02 02 2011
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 TIE REMAINS AS IDENTIFIED ABOVE.
FUNERAL NAME O E�F ESTABLISHMENT ADDN CITY AND STATE N.Y.STATE REe.#1`
ESTABLISHMENT John Fa(.rink &Son.Inc.Funeral Homee 3129 Perry Avenue Bronx, New York 00936
APPLICANT NAME Of N.Y.STATE MENDED FUNERAL DIRECTOR(PRINT) MGNA N.Y.STATE LAC.#
ribriVA
Wiliam Curran senor.s.a.oN...r A EAMMed 00808
PERMISSION 18 HEREBY GRANTED TO DISPOSE OF 7HE R= : ,-- • S. :OVE
NOTICE: This permit is not valid without the seal of the Department 6•.4,P `•
oI Health and Mental Hygiene;or if it has been ooaected, £ '< • •
interlined or altered In any manner. a i.' : City Registrar
YR 21(REV.7/09) FEE PAID$40.00 DATE 02 J 01 i�011 *4._�7-..! . By WM*Thomas
um DO YYYY 46.737.
6.737 CK