Zhang, Chen 1�6v
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 27,2020 12:50 PM 156-20-036458
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION ------------ceRnFicnre riiiMeeR
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF
Chen Zhang 1 71 Female EVENT 04 24 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Queens Mount Sinai Queens
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
METHOD ❑ INTERMENT CREMATION
CERTIFIER OF MEIMLI Adrienne Grande
Alexandra Martinez DISPOSAL ❑ OTHER M.E.CASE#Q20023516
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 04 29 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
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) S TU J J N.Y.STATE LIC.#
APPLICANT
Thaddeus W. Baxter o IlyAuftnGcated 10227
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department �!�� ��•:
of Health and Mental Hygiene;or if it has been corrected,
interlined or altered in any manner. City Registrar
VR21(REV.7/09) FEE PAID$ 40.00 DATE 04 ) 24 1 L020 %.�����:* By_Serv_ice Ev_ital
MM DD YWY QR.COX
Public Health Law Sec. 4145(2b) 13 6
Receipt
Human remains of delivered on , 20
t -
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#