Xu, Eric 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 23,2020 08:54 AM 156-20-033820
EVENT:(CHECK ONLY ONE) M DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE I SEX I DATE MONTH DAY YEAR
OF ( )
Eric Xu 82 Male EVENT 04 21 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Queens 14714 84th Rd,Apt 6B,Jamaica NY 11435-2249
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER ///CREMATION APPROVED BY:
CERTIFIER METOD ❑ INTERMENT OF CREMATION J ME/MLI Joseph Pestaner
Anne Hoffa DISPOSAL ❑ OTHER 5`M.E.CASE# Q20021652
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
OF
DISPOSITION Pine View Crematory Queensbury, NY DISPOSITION 04 24 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. 1 9807 Ascan Ave Forest Hills NY 00603
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
APPLICANT
Thaddeus W. Baxter na Authenticated 10227
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE QUESTED ABOVE.
••�••'riy
NOTICE: This permit is not valid without the seal of the Department a;'�"` "`+.!•� 1-OAVAIZ�
of Health and Mental Hygiene;or if it has been corrected, �• •<
interlined or altered in any manner. City Registrar
VR 21(REV.7/09) FEE PAID$ 40.00 DATE 04 j 22 /2020 • By_Service_Evital
MM DD YYYY •••••'t
Public Health Law Sec. 4145(2b) 0 1. 3 61 4
Receipt
Human remains of y delivered on = , 20
f-
Pine View Cemetery Representing the funeral Mome named on burial permit
Official Funeral Directors Reg.or License#