Barcomb, Elizabeth ti,,
NEW YORK CITY THE CITY OF NEW YORK-DEPARTMENT OF HEALTH AND MENTAL HYGIENE 1C:F
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE
November 12,2021 08:33 PM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-21-054633
EVENT:(CHECK ONLY ONE) NI DEATH ❑SPONTANEOUS TERMINATION 0 INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF
Elizabeth A Barcomb 65 Female EVENT 11 12 2021
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Manhattan New York Presbyterian Hospital
NAME OF PHYSICIAN OR MEDICAL EXAMINERS NUMBER METHOD N�INTERMENT ❑ CREMATION CREMATION APPROVED BY:
CERTIFIER OF ME/MLI
Samantha Greissman DISPOSAL ❑ OTHER M.E.CASE#
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
OF
DISPOSITION Pine View Cemetery Queensbury, NY DISPOSITION 11 19 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 Riverdale Funeral Home 5044 Broadway New York NY 01475
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
APPLICANT c f)
""
Nicholas Apostle Signature ENGonm"""°'l"° 10097
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE , (fib '' �,•UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department i°••off •• .
of Health and Mental Hygiene;or if it has been corrected, •'•h • ._ 'ifr
interlined or altered in any manner. ,�l s,1,;`y
S.'• ;7 Ciy Registrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 11 / 13 /2021 4' By Ser-V-ice Eyital
MM DD YYYY %OFNet
Public Health Law Sec. 4145(2b) 012880
Receipt
Human remains of r - s delivered on i 4 , 20 f
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
BARCOMB L,..,
1'
NAMEElizabeth Barcomb Age: 65
Lot Owner: David Barcomb
Lot# Erie 24 E Grave# 2
Case: Concrete
Died: 1 1 . 1 2.21 Interred:1 1 . 1 9.21
Funeral Home: Regan Denny Stafford
Cemetery: Pine View