Cutignola, Thomas t 4a 23L
NEW YORK CITY THE CITY OF NEW YORK-DEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
AND MENTAL HYGIENE MARCH 20, 2017 01:21 PM PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
156-17-012140
EVENT:(CHECK ONLY ONE) El DEATH ❑SPONTANEOUS TERMINATION ❑INDUCED TERMINATION CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY YEAR
OF (YYYY)
Thomas Cuti nola 64 Male EVENT 03 16 2017
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Manhattan The Mount Sinai Hospital
NAME OF PHYSICIAN OR MEDICAL EXAMINER'S NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD ❑ INTERMENT M CREMATION
OF ME/MLI Robert Mos
Yves Jean, PA DISPOSAL ❑ OTHER M.E.CASE# M 17006597
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATE MONTH DAY YEAR
OF (YYYY)
DISPOSITION Pine View Crematory Queensbury, NY DISPOSITION 03 22 2017
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 Bergen Funeral Service(Woodhaven) 114-30 Rockaway Boulevard South Ozone Park,New York 00170
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE LIC.#
APPLICANT
Matthew Connors �� Signature Electronically Authenticated 14131
PERMISSION IS HEREBY GRANTED TO DISPOSE OF THE R , • :EQUES 'BOVE.4)
NOTICE: This permit is not valid without the seal of the Department ..°E.'�` �': /,) !
of Health and Mental Hygiene;or if it has been corrected, i'.'•
..• ` i i`
interlined or altered in any manner. <; i'41,y '.i.o ff City Registrar
VR 21 (REV.7/09) FEE PAID$ 40.00 DATE 03 / 20 /2017 *�'F• ' 4,.'" By Erwin Eady_
MM DD YYYY Cyh,9 N`wV
jLA.16,.64. bet, ��4. /'
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