Vizioli, Fernando 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 13,2020 11:34 AM 1__56-20-02506.8___
EVENT:(CHECK ONLY ONE) N DEATH El SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DOTE MONTH DAY (YYri)
Fernando Vizioli 73 Male EVENT 04 12 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Queens 6820 Selfrid a St,Apt 3K Forest Hills NY 11375-5704
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER r CREMATION APPROVED BY:
CERTIFIER METOD ❑ INTERMENT CREMATION OF J ME/MLI Floriana Persechino
Margaret Prial DISPOSAL ❑ OTHER S`M.E.CASE# Q20016792
NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
AR,)
PLACE OF OF
DISPOSITION Pine View Crematory Queensbury, NY DISPOSITION 04 22 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) SIGNATURE N.Y.STATE LIC.#
APPLICANT
&"-iC2)1=Steven Duea 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 ��� i
of Health and Mental Hygiene;or if it has been corrected, r
interlined or altered in any manner. 'o City Registrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 0 M / oo /2020 NEB l By Service Ev_ital
Public Health Law Sec. 4145(2b) - 0 1 5
Receipt
Human remains of delivered on , 20_
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#