Stafford, Shyla Sue rr el Le
.1
NEW YORK CITY THE CITY OF NEW'YORK-DEPARTMENT OF HEALTH AND MENTAL HYGIENE LF V 3
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
October 12,2022 05:32 PM 156-22-046427
EVENT:(CHECK ONLY ONE) g DEATH 0 SPONTANEOUS TERMINATION 0 INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
EA )
OF
Shyla Sue Stafford 27 Female EVENT 10 11 2022
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Manhattan Mount Sinai West
NAME OF PHYSICIAN OR MEDICAL EXAMINERS NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD ❑ INTERMENT CREMATION ME/MLI John Haves
OF
John Hayes DISPOSAL ❑ OTHER M.E.CASE# M22031959
NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
PLACE OF
OF (YYYY)
DISPOSITION Pine View Crematory Queensbury, NY DISPOSITION 10 21 2022
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 Legacy Funeral Service, Inc. 725 E Gun Hill Rd Bronx NY 01877
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
APPLICANT �}
Rayna Hewitt . 2 ,7lQi ure Electronically Authenticated 11607
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE , $t NIf, •UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department ~i: • ��.'•i� Y /,,y
of Health and Mental Hygiene;or if it has been corrected, •�,1;x, . •
interlined or altered in any manner. i ,ir:' �., 'i Cly Registrar
40.00 DATE 10 / 13 /2022 `n:- By
Service Evital
VR 21(REV.7/09) FEE PAID$ MM DD YYYY F •
U .
0 I. 3 4 4
Public Health Law Sec. 4145(2b)
Receipt
Human remains of " delivered on , 20
) •
Pine View Cemetery Representing the funeral home named on l?uyial permit
Official Funeral Directors Reg.or License#