Chevalier, Dolores 41 a1
NEW YORK CITY THE CITY OF NEW YORK—DEPARTMENT OF HEALTH AND MENTAL HYGIENE ,t Q!I
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE MARCH 27,2014 05:06 PM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-14-012750
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (YYYY)
Dolores S Chevalier 62 Female EVENT 03 26 2014
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW YORK CITY
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 Albert Leung
Rebecca Repetti, NP DISPOSAL ❑ OTHER M.E.CASE# M14001956
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DAA (YYYY)
TE MONTH DAY YEAR
DISPOSITION Pine View Crematory Queensbury, NY DISPOSITION 03 31 2014
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 I ADDRESS CITY AND STATE N.Y.STATE REG.#
FUNERAL
ESTABLISHMENT Cross Island Funeral Service, Inc. 1149-20 Northern Boulevard Flushing, New York 00393
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE //�� N.Y.STATE LIC.#
Edwin R. Lins ��l/ 1. �t! Signature Electronically Authenticated 12100
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE R , r`,.. .it ' QUES 'BOVE. 1
of •V!`••
NOTICE: This permit is not valid without the seal of the Department . a,!•.� �f�! / 40r 14
of Health and Mental Hygiene;or if it has been corrected, . '•, " _ ..sue
interlined or altered in anymanner. II <• ''. '`•�
1 a• ��� ` •� City Registrar
VR 21(REV.7/09) FEE PAID$ 40.00 DATE 03 / 27 /2014 ;,•:. '+ By Erwin Eady_
MM DD YYYY
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