Chessa, John NEW YORK STATE DEPARTMENT O
Vital Records Section Burial - Transit Permit
Name First Last Sex
John Chessa Male
Date of Death Age If Veteran of U.S. Armed Forces,
April 10,2020 78 War or Dates
H Place of Death Hospit stitution or
tfressZ City, Town or Village Mount Pleasant Street Westchester Medical Center
pManner of Death ❑Natural Cause ❑Accident ❑imlqmcide ❑Suicide ❑Undetermined ❑Pending
W Circumstances Investigation
C Medical Certifier Nime Title
Danie$Greenber t , DO
ress
100 Woods Road,Val ' 10595 °t
Death Certificate Filed District Number Register Number
City, Town or Village 'ant Pleasant 5957
❑Burial Date Cemetery or Crematory
May 5, 0 Pine View Cemeteryand Crematorium
❑Entombment Addr
essdNW
❑x Cremation 21 Road, Queensbu ,NY
D Place Removed
Z ❑Removal and/or Held
O
and/or Address
t Hold
N
O Date Point of
IL
N ❑Transportation Shipment
b by Common Destination
Carrier
❑Disinterment Date Cemetery Address
❑Renterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Clark Funeral Home, Inc. 00340
Address
2104 Saw Mill River Road, Yorktown Heights,NY 10598
Name of Funeral Firm Making Disposition or to Whom
H Remains are Shipped, If Other than Above
2 Address
tY
W
a Permission is hereby granted to dispose of the human remainsOde._ scribe ove as irlicated.
Date Issued 5/4/2020 Registrar of Vital Statistics +�JQ�•�- t
(signature)
District Number 5957 Place Mount Pleasant,New York
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
W Date of Disposition St W7z Place of Dispositio f i Zt - VIS- L(
W (address)
N
fY (section) (lot number) (grave number)
pName of Sexton or Person in Charge of Pr mises Ai'.L t 1(t
Z (pldbse print)
W
Signature Title *^ Alhd
(over)
DOH-1555 (02/2004)
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