Lohse, Reinhard # 3�
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 16,2020 12:49 PM 156-20-028225
EVENT:(CHECK ONLY ONE) IN DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION - cEaTiFicnTe riiiilnaeR
NAME First,Middle,Last AGE SEX DATE MONTH DAY YE,AARRI
OF
Reinhard Lohse 70 1 Male EVENT 04 14 2020
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW PORK CITY
EVENT Queens Lonq Island Jewish Medical Center
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER ///CREMATION APPROVED BY:
CERTIFIER METHOD ❑ INTERMENT CREMATION J OF ]� ME/MLI Michael Vaivao
David William Silver DISPOSAL ❑ OTHER S`M.E.CASE# Q20018891
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY (Y YR)
OF
DISPOSITION Pine View Crematory 1 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
Steven DUca / Signature Electronically Authenticated 1 14007
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE RE UESTED ABOVE.
NOTICE: This permit is not valid without the seal of the Department ii"'`� +.'ST
of Health and Mental Hygiene;or if it has been corrected, •-2
interlined or altered in any manner. City Registrar
19 VR21(REV.7/09) FEE PAID$ 40.00 DATE 041 / DD /2020 900. �eNyd By_Service Ev_ital
Public Health Law Sec. 4145(2b)
Receipt
Human remains of f" , delivered on , 20_
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#