Rinchey, Walter NEW YORK CITY THE CITY OF NEW YORK—DEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
April 21, 2020 09:19 AM 156-20-03218.8__
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION -CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX I DATE MONTH DAY YEAARR)
OF
Walter Rinche 82 Male EVENT 04 20 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW PORK CITY
Queens 12360 83rd Ave, Kew Gardens NY 11415-3452
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT :4 CREMATION CREMATION APPROVED BY:
OF ME/MLI Corinne Ambrosi
Anne Hoffa DISPOSAL ❑ OTHER M.E.CASE# Q20020839
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE rO4
DAY YEAR)
DISPOSITION OF
Pine View Crematory Queensbury, NY DISPOSITION22 2020
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 Fox Funeral Home, Inc. 9807 Ascan Ave Forest Hills NY 00603
APPLICANT NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE �� N.Y.STATE LIC.#
3
`J y�
Steven Ducal /�/y�i Signature Electronically Authenticated 14007
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE QUESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department r`�••'• �a T,
of Health and Mental Hygiene;or if it has been corrected, �• •_ _ /"
interlined or altered in any manner. ��'
.9 City Registrar
VR21(REV.7/09) FEE PAID$40.00 DATE 04 / 20 /2020 ' •• . ; By Service_Evital
MM DD VVYY
Public Health Law Sec. 4145(2b) 013592
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representipg the funeral home named on burial permit
Official Funeral Directors Reg.or License#