Lomnardo, Anthony Alfred 11/20/21,2:29 PM Lombardi Permit.jpg 7i'.N J Q I
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NEW YORK CITY THE CITY OF NEW YORK-DEPARTMENT OF HEALTH AND MENTAL HYGIENE
DEPARTMENT OF HEALTH OFFICE OF VITAL RECORDS
ANDMENTAL HYGIENE PERMIT TO DISPOSE OF OR TRANSPORT HUMAN REMAINS
November 20,2021 08:43 AM 156-21-055823
EVENT:(CHECK ONLY ONE) )$1 DEATH 0 SPONTANEOUS TERMINATION 0 INDUCED TERMINATION —...... CERTIFICATE NUMBER
NAME First,Middle,Last AGE SEX DATE MONTH DAY ( )
OF
Anthony Alfred Lombardi 45 Male EVENT 11 16 2021
BOROUGH NAME OF HOSPITAL OR INSTITUTION OR STREET ADDRESS
PLACE OF NEW YORK CITY
EVENT Queens 7801 164th St,#B,Fresh Meadows,NY 11366-1228
NAME OF PHYSICIAN OR MEDICAL EXAMINERS NUMBER CREMATION APPROVED BY:
CERTIFIER METHOD 0 INTERMENT X CREMATION ME/MLI Kristen Landi
OF Q21037243
Kristen Landi DISPOSAL 0 OTHER M. CASE
PLACE OF NAME OF CEMETERY OR CREMATORY(OR DESTINATION) CITY OR COUNTY AND STATE DATEA MONTH DAY l �
DISPOSITION Pine View Crematory Queensbury,NY DISPOSITION 11 22 2021
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 ESTABUSHMENT ADDRESS CITY AND STATE N.Y.STATE REG.#
FUNERAL
ESTABUSHMENT Mangano Funeral Home 1701 Deer Park Ave Deer Park NY 01099
NAME OF N.Y.STATE LICENSED FUNERAL DIRECTOR(PRINT) SIGNATURE N.Y.STATE UC.#
APPLICANT /*. 12165
Kenneth Lysak ,�.,....I. .,an.�.e
PERMISSION Is HEREBY GRANTED TO DISPOSE OF THE RE , ,r*ti'+/, QUESTED ABOVE. ///AJ'�l/�s1
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Interlined or altered in any manner. t'.•
t%�1e ,`_'a g City Registrar
VR 21(REV.7/09) FEE PAID$40.00 DATE 11
/ 17 /2� t~ , o' By Service Evitai
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Public Health Law Sec. 4145(2b)
Receipt
Human remains of • delivered on , 20 _
Pine View Cemetery Representing the funeral home named on bur�iiermit
Official Funeral Directors Reg.or License#