Wang, Hsueh Cheng {( A 3 90
NEW YORK CITY THE CITY OF NEW YORK—DEl?ARTIfNT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF JTAL RECORDS
AND MENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
April 19,2020 03:54 PM 156-20-030906
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION -CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (YYYY)
Hsueh chen Wan 100 Male EVENT 04 17 2020
PLACE OF BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT NEW PORK CITY
Queens Union Plaza Care Center
CERTIFIER
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER METHOD ❑ INTERMENT CREMATION
CREMATION APPROVED BY:
�
OF ME/MLI Ian Bautista
Jitendra Tolia DISPOSAL ❑ OTHER M.E.CASE 9 Q20020655
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
DISPOSITION OF (YYYY)
Pine View Crematory Queensbury, NY DISPOSITION 04 20 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.
FUNERAL NAME OF ESTABLISHMENT ADDRESS CITY AND STATE N.Y.STATE REG.#
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.#
Steven Duca (,�{',(,� 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 ���• ttor
i
of Health and Mental Hygiene;or if it has been corrected, �• • i2�`�G�(�'��l/ Q/��./'+�
interlined or altered in an manner. 2 •�'
y City Registrar
VR 21(REV.7/09) FEE PAID$ 40.00 DATE 04 / 19 i 2020 •�, By_Seryice_Ey_ital
MM DID YYYY OF
Public INal aw Sec. 4145(2b) `' 013 57
b
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#k