Pettit, Donald VSYI NI OHiIl 99t 3309,
�' 1 N .Fa �'4V N^�. ,r' 7'iifiy' ? ri ;,. R w j`- •- $a•yt n,N `G-a�ri,'. 3 }`'S�i 4- - So- S V
,�� S �S't� t--^<^�.,���� F r �i��� sf ,r^.'tt� i,•-^ ,:i1 '^�S,--�v,•-•---. i- ,t r•^-.y 7r•^t �k;---,. w, ,.,sp ••-^--1.'�
°.d a a` e• 0 0 0 � ^ *'*\-- --"L'N l a '.
•., eirir4* a e 1,-;r: o/�"\c ti -'�°''\a/`' :_a 1` e "t_e - a .-. a a _ a „e,/k' :,a,_1 �.s
tiM'�%n s A- ,c`R�';f ,r`:a�"A�F� r R -.a `"'q '�i"%a a rt H m+�.R•i` `"�'':%�,T r..r;,�"`w,, a,.'q�,..' A'm R ti af'a a 'z� , '.
140 e• '.
,
� re• � � r r � e r r � r e � dI
' ; , -• !1r P wry GROVE MEMORIA! GARDE pis CREMArORl 7::
I ; 549 Morristown Road • Old Bridge, NJ 08857 r3,
1`- .yc' h t o
.▪,,,,,4
# rlblr' C#
o
„(,(s: „ " )
CERTIFICATE OF CREMATION
k� , This certifies that the remains of 04.(-kro.,,,..�-A J, Pik ` k 4(,)
k \
� ¢ Who died at a.,,,..9.,�.1�s -� « � e„� � 1,-.
?r Age C Date of Death l \-L\z-\ ij
• k Was Cremated at LibertyGrove Memorial Gardens Crematory, '4
) ti
Ft :` ry [
: on t \''' •
Cremation No. `� �z e �
3
Liberty Grove Memorial Gardens Crematory i�
''-'( 4 0 a 4 p '. .:> 4 ,her -- _ - •3,
fl
• .✓ ,,,_�. a.._..- v i,... A ak-.✓ ! ✓,. �.......� -4, v ✓ 4,�.-.✓*......., l's .f i, ,✓ ..r >ti. 4 F i*., ,.� ;...i §' -,„ ✓ Syr-.,.
�`c ��q�g a �`' �`�'��.,���, aY�? �� �.- � � �`__ .,..' 3! .ski, � ° , _. , � , -_ .A „ 1 .n$
+: Y,- 1 ``t s' '&i / 'fir ' 4,;-;.i1s,- ":.a s,z,a,.,;4 12)4�a'&:..<j;; ,x a.�,•;,s�„ ir- .', v.t' (.:! ) ' `"i- r'' I t ,tn' .: .Z.''',.'
.:,
,.�,, �,. VITAL RECORDS CERTIFICATE ,,,� � `� ,., � �,
i 1 a 3 e c " - -n a- �r ,t3
,! !, Vf, DEATH TRANSCRIPT ° L„ .A.
114
DATE FILED THE CITY OF NEW YORK---DEPARTMENT OF HEALTH AND MENTAL HYGIENE
LF f:
CERTIFICATE OF DEATH Certificate No. 3'
1°� NEW YORK CITY 156-21-002201
DEPARIMENCOFH}ALIH
,:.
AND MENTAL HYGIENE
Jan 13,2021 06:06 PM 1.DECEDENTS
LEGAL NAME DONALD PETTIT
(First,Middle,Last,Suffix)
2a.New York City 2c Type of Place 4 0 Nursing Horne/Long Term Care Facility 2d.Any Hospice care 2e.Name of hospital or other facility(If not facility,street address)
r Place 1 it Hospital I anent 5 O Hospice Facilityin bast 30days
H 2b. Borough P nP sp
4_ OI 2 0 Emergency Dept./Outpatient 6 0 Decedent's Residence 2 No1 CI s
LL: Death Brooklyn 30 Dead onArrwal 70 Other Specify 30Unknown
Maimonides Medical Center
N
o.t' Date and Time 3a.. (Month) (Day) (Year-yyyy) 3b.Time O AM 4.Sex 5.Date last attended by a Physician
Fa of Death
mm dd yYYY
�_ January 07 2021 fit 47 =GPM Male 01 07 2021
u c 6.Certifier: Icertiy that death occurred at the time,date and place indicated and that to the�est of knowledge traumatic Injury or poisoning DID NOT play any part in causing death,
arid thatdeath did not occur in any unusual manner and was due entirely to NATURAL CAUSES.See Instructions on reverse of certHlcate.
U _ (/////may 140.
ii V 0 Name of Medical Certifier XIAO MA Signature ( t (`%%'(a RNit
PA
8 (Type or Print) _ y ▪ `4 Signature Electronically Authenticated': A
s Address 4802 10th Ave Brooklyn,NY 11219 ,r _ 'License Nd.' 0.088221
Data JAN-7-2021
7a.Usual Residence State 7b.County 7y.Atli oelowi 7d:-,Street and Number Apt.No. ZIP Code 7e.Inside'City
New York Kings . "Brooklyn `` E
' -860 ),38th$t 11210 1 BS Yesa20 No
8.Date of Birth (Month) (Day) (Year-yyyy) 9.Age atlast birthday Under 1 Year. . -Under 1 Day:;;' 10.Social Security No.
(years) Months `Days Hours Minutes
September 07 1953 ** - »• *.* -*a*
,` -- - ,,• ,a , ;. S, , 130-46-0512
11 a.Usual Occupation(Type of work done during most of working life. '1l b.Kind of business or•industry ' 112.Alases or A_KAs`
Do pot use"retired")
Disabled .Unknown' . ******
13.Birthplace(City&State or Foreign Country),14,Education(Check the box thatbest descrioes`the highest degree or level of school comptetedat the time of death)
1 0 8th grade or less;none; O$4 orris cofoge cred CI no degree 7 Master's de{Iree(e.g.,MA,MS,MEng,MEd,MSW,MBA)
§ Long Island, New York '2 o 9th 1.2thgrade'no diploma 'Sty Associate degree(e g A9:AS) 8 0 Doctorate(e.g)PhD,EdO)or
ytc•
f f 3 Q High school graduate or GED ''6P,Baclielor's'degree to g BA,AB,SS) i ,Profession de
> 1 dIr•pree(e.g.,MD,DOS,DYM LLB,JD).
15.Ever in U.S, t 6.MantaifPartnersl(ipr up-at time of death_ .``' f .17.'Sur lvinp Spouse s/Partner's Name(Prior to first ritar}iage)(FIrst Middle,Last)
UArmed Forces? 1 O Married 20 d egr},c,Partnership 3 0 Diuorc F `•
F it 10 Yes 2®No 4 0 Married,but sep®,;„,5 Never Married 6 tJ Idowed
OC g 7 Cl Other,Specify r)4. " , 'tip nkn'own +t*t**# '
4'a 18.Father/Parent Name(Prior to first marnage)#(Plrst Middle,lest) r 19{Mo(he- (Parent Name(prior to first marriage)(First:Middle,Lest) --
ot Melvin John Pettit EU abeth$lenoh KQnt'y
20a.Informant's Name ^' ,:20b.Relationship to Decedent Zoo/Address(Street and Number/ Apt.No' City&Stale ZIP Code)
a� Shadasha White {.{ Guardian 860E 38th St Brooklri,NY 11210
5 21 e.Method of Disposition 21b.`Place of Disposition(Name of cemetery ctrematory,other place)
10Burial 2GYCremation 30Entombmertt 40 City Cenyetary iF
5 0 Other Specify Liberty Grove Crematory'
„
t° 21c.Location of Dispositun(City&State or Foreign Country) p1 d.Date of mm dd
yYYY
3r = v `.. Disposition -
Old Bridge, New Jersey F , *; 01 14 2021
22a.Funeral Establishment i
22b" ress-($treet and Number City&State ZIP Code)
;z
All Boro Cremation Services 1289 Forest Ave Staten Island,NY 10302
No Correction History'**
•
VR IS(Rev.01,20)
LVT202 1 0 1 24585• January l4,2U21 =
/./ f ` l This is to certify that the foregoing is a true copy of a record on file in the Department of Health /� U J^r I �+ 1�
1, r , ,,� _ and Mental Hygiene.The Department of Health and Mental Hygiene does not certify-to the truth of11 0 40/4 4 1 Y Q� l�rr -,
i YA P YA N rrj • '.
fin,J J'y L'`, the statements made thereon,as no inquiry as to the facts has been provided by law Gretchen-Van Wye,PhD,CityR gistrar sill) i I w
1, o, ,"1 Do not accept this transcript unless it bears the security features listed on the back_Reproduction 11 : <.i,. �/ 1
20ill' r/.o �i), 'mil ` P P tY I)I III`II II II II 11111
11111
1111
II S,•,S i y t Yy"1V� '
}� ;;{{ t<<` �F11rf /gF- or alteration of this transcript is prohibited by§3.19(b)of the New York City-Health Code if=the i 1 f } � ••
tia, ka�\��. w. q rfl purpose is the evasion or violation of any provision of the Health Code or any other law. 9 ,, y
i` 1Mtir ` i.'/i9.1p , 1400000515343 ���� 4 ��
„ _._._� rlr L '^a � _ '-Ei.,` = a,.. . .,.._ - - - -,..
PETTIT LFI
NAME Donald Pettit Age: 67
Lot Owner: Donald Pettit
Case Worker SHadasha White
Lot# Grave#
Horicon 44 D 1
Case:
Urn
Died: 1 /7/2 0 21 Interred:1 /2 9/2 0 21
Funeral Home:
Liberty Grove Crematory
Cemetery: Pine View Cemetery