Baird, Zachery fie
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NEW YORK CITY THE CITY OF NEW YORK-DEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE
May 28,2021 05:55 AM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-21-028710
EVENT:(CHECK ONLY ONE) yet DEATH D SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
First,Middle,Last AGE SEX DATE MONTH DAY YEAR
NAME OF
Zachery Baird 26 Male EVENT 05 28 2021
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 EXAMINERS NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD ❑ INTERMENT X CREMATION mu mu Leashawn Peaks
OF
Faisal Mehmood DISPOSAL LI OTHER M.E.CASE#B21019583
NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
PLACE OFOF
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DISPOSITION Pine View Crematorium Queensbury, NY DISPOSITION 06 03 2021
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 J. Fox Funeral Home, Inc.(Bronx) 203 E 201st St Bronx NY 00897
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
APPLICANT estizailcCorininee
Thomas Roemmelt 99rowreEbcwncelyAulhenheel80 13080
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE 0 i.,.. •UESTED ABOVE.ef• /
NOTICE: This permit is not valid without the seal of the Department ` .,. `:"N• . ' / `?�o 'U/Q'y/i
p.....••••
of Health and Mental Hygiene;or if it has been corrected, 4 '`•
` » Sc,
interlined or altered in any manner. a�: Vr4�.e City Registrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 06 / 02 /2021 V.: • ,y i By Service Evital
MM DD YYYY C7/)'Of NE•v
' F.
Public Health Law Sec. 4145(2b) 01 s 8 31
Receipt
Human remains of delivered on , 20`
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Pine View Cemetery Representing the funeral home named on bjrial,permit
Official Funeral Directors Reg.or License# r