Khitsenko, Mykhaylo 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 03:09 PM 156-20-032505
EVENT:(CHECK ONLY ONE) ®DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (YYYY)
Mykhaylo Khitsenko 67 Male EVENT 04 20 2020
PLACE OF NEW YORK CITY
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
EVENT Queens 11865 Metropolitan Ave,Apt 2Dd, Kew Gardens, NY 11415-2002
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD ❑ INTERMENT I� CREMATION ME/MLI Joseph Pestaner
Amanda Krausert DISPOSAL ❑ OTHER M.E.CASE,, Q20021088
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY (YYYY)
OF
DISPOSITION Pine View Creatory 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. 9807 Ascan Ave Forest Hills NY 00603
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGN� � N.Y.STATE LIC.#
APPLICANT ��^vJ1►(( ''
Steven Duca i Signature Electronically Authenticated 14007
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, • �� V .
interlined or altered in any manner. 0 City Registrar
VR21(REV.7/09) FEE PAID$ 40.00 DATE 04 / 22 /2020 ••�•��• By_Serv_ice Ev_ital
MM DO YYYY 4►y� '�
Public Health Law Sec. 4145(2b) 9 1 3 6 1 -i
Receipt
Human remains of delivered on , 20 ,11
AI,
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#