On December 31, 2019 a
EXHIBIT(S) - A (Motion #001) Certificate of Death Redacted per 22 NYCRR - Certificate of Death Redacted
was filed
involving a dispute between
Martha N Mendoza,
and
Ashok Kumar,
Deepak Sharma,
for Torts - Motor Vehicle
in the District Court of Nassau County.
Preview
FILED: NASSAU COUNTY CLERK 02/01/2021 01:27 PM INDEX NO. 618235/2019
NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 02/01/2021
Ex "A"
FILED: NASSAU COUNTY CLERK 02/01/2021 01:27 PM INDEX NO. 618235/2019
DOH-1951
NYSCEF RECORDED
DOC. NO.
(B2011) 19DISTR1CT NEWYORK STATE RECEIVED NYSCEF: 02/01/2021
2952 DEPARTMENTOFHEALTH
"""" "" 131-2020-00028223
656 CERTIFICATE OF DEATH STATE FILE NUMBER
FIRST
1.NAME: MIDDLE LAST 2.SElt OFDEATH:
3A.DA*E I 38.l•0UR:
MALE FEMLE MONE 0AY YEAR I Approx
Ashok Kumar 1 D2 04 01 2020 | 11:30 PM
0FDEAm:NCSP
¾ PLACE TAL HOSPITAL HOSP1TAL MURSINGPWAFc HOSPICE OTHER 4B.IFFAC1LP..
DATEADMITTE0
neckone) DCAER DUTPATIENT INPATIENTHOME RESIDENEFACILITY(SuciM. MONTH DAY VFAR
O o O o o o o 03 21 ] 2020
OFFACIllTY:
4C.NAME UT giveMGren)
nodaciEly, I 4D.LOCALITY:
(Check
ontaMspecM I CECOUNTY
0FDEATit
I CITYVILLAGE TOWN
Plainview Hospital | O O O Oyster Bay Town |Nassau
$TITUTION? citycrton emmty
MtiMwname,
(r!yeLspecify ad state)
ND YES
I
0FBIRTH:
6.DATE m I 68.If UNDER
5AAGE 1Y{AR I $6,(FUNDER
1DAV I 7A.CITY
MD5TATE yad I 7B,If AGE
0FBIR'ItiffnotUSACoutr UNIRR
1YEAR, CFHOSPITAL
NAME OF
YEARSI ENTER I ENTER1 I Repy/Presee | BIRW
NCIITH DAY VFAR mones ms I hars. rnine I
. &SEWEDINLl.S.
FGRCE52
ARMED
(Sprdyyearsi
9.DECEDENT
CFHISPAMC avewee- " - " -state
ORIGIM½ectnmeevesthebes½smen•urkemedecewa5rassrHrsumen.uac
10.DECEDENTS
RACE wMr
me m
anmmrmerorNruere
A No. naiSpanish.%ssamc/Laimo
B Yes. MtxCM
Mex.cm. Arrentart
CEcarg A] Wehcam B Blad or IridiarlD] Caritse
AmentarlC Agim
O 1 C Yes.PumRai D Yes,C n Filipino f Jappege G Korea H] htnarme
E 01A!r
Spanigh/Higppic/Luira
i5pec -1 Guamarän
erÇnamorroM $gmcan
() C d NkrPWess'deurtedshirhrsfdepwar
11.DECEDENT3EDUCATEDN Wpp#.
evyMsweprg41pø#sqSmp
R American lariaorAlaska
Naine
(spsdy)
grade
S8th 2 frthd26
gf
a de.
no dders 3 Hghs ch as
raduate
GED
P Other Ashr{speedp R Other
PachtWIacerspeMyl
Somecolege Ipul
credpl.
nodegree5 AssacMe's degree 6 Bachelor
sdegree
7O wamismree aO Decw:WPdess.onCeget
12.50CIALSECuniTT
huusEn: 13,MARITAL
STATLIS: 14.SURVEVING
SPCIN:
•• 68 ME9ER
MARRIEDMARRIEDWIDOWEC DIVDRCEDSEPARAFED EmerDirthname9spouse
954 O 1 2 o 3 O a O s "'"®"®™"" Kanta Rani
1stusuaLoCCUPATICNabøe OFBUSINESS0R
158KIND INDUSTRY: ' 15C.
NAMEAND
I.0CAL
IIYCE FIRM
CCMPANY
OR
raimr)
Ù Taxi Driver |Taxi Self Employed
tili RESIDENCE: 168,
ComcrRegion/Promot 15C. (Check
LCCAllTY: orne
adspedly) ' 16fJF
CITY
ORVILLAGEJS
RESIDENCE
(SinorCoavrry nat SA- CLTY VILLAGETOWN ' WITHIN ORVILLAGE
CITY LIMITS†
IF SPECWDWN:
Z NY Nassau O O O Oyster Bay Town | OYESDNO AD.
160. STREET
ANDNUMBEROFRESIDENCE: I 165.
ZIPCCDE:
11801
FERS- MI LAST
NAME0F
U.BIRTH FIST MI LAST 16.DIRTH
NAME0F
FATHER
/ PARENT: MOTHER
/ PARENT:
Raundi Lal Santosh Rani
0FINFORMArE
ISA.NAME 96.MA).WG
ADDRESS:
findu¢tlip
codel
Kanta Rani Hicksville Hamlet, NY 11801
20A.1 2 REMATION
OSWRIAL aCIf0LD5ODOMATION2DB.
3OREkDYAL PJCEOF8URIAL
CREMATION. OROTHER
REMOVAL I 200.LCCATION:
DISPOSITlDN. crtomand
(City state)
MONTH DAY YEAR
04 06 2020 Nassau Suffolk Crematory Lake Pen nh Hamlet, New York
21ANAhE
ANDADDRESS HGME-
3FFUNERAL 21BJEGISIrwiün
munn:
MOloney's Lake Funeral Home & Cremation Center
218
132 RGif .Aú.na Avenue, Lake PW'±r Harolet, NY 11779
22ANAME0F
FUNERAL
DIRECTOR: 0F NERAL
2281515NAÏÜfE OlRiCTOR REGISIRAÏÏ0NNÙMBER:
22C.
Lauren Lombardi LauranLombardi£&amricaKy Sigmd 14740
OFREGISTRAR:
SIGNATURE
23A. I 23B, FILID:
DATE I 24A. ORREMOVAL
BURLAL PERMIT
ISSUED
BY: I 248.DATE
IS$JED:
vokTH CAY YFAR I MDNTH DAY WAil
ITEMS25TilRLI35COMP
LETED
BYCEATIFYlNGPHY -- OR- Curiú•i-Gu•«ER's PHYSICIAN
SICIAN ORMEDICAL
EXAMINER
25A.CERTIFICATION: Tothebestof my knowledge,deathoccurredatthetime,dateard placeancdueto thecausesstated.
Name:
Carliners UcenseAro Signanf
re:
yart.7ames
htn&tDO Manih cay Year
Ryan James Pamell, DO 285620 £&am,s-,gy gged 04 05 2020
Cerwier
STide:O AL1ending PhysicianO Physician
acting PhysicianMffefr
ofAltending
onbehaH
10 coroner 2O Medical Exarniner
/ Deputy Exitmjrier
Medical 888 Old Country Rd, Oyster Bay Town, NY 11803
258.11coroner enter
isnotaphyssrilp. CorowsPhysidani
mnle&litle Ucense
ho.: Signarwe h*L
| |
25C.IIcatlier
isnotattsading
physicim.
enter Physient
Attending name
&title UmseNo.. Mdrost
physiri
26AAttending Mem- cu wr som car agia Mom Dgy Ye:1 260,Pro Man9 Day Veg Tim
deceased: 03
attended byattendinochysicia D"'
mu| | 22 2020 04 | 01 | 2020 | 03 | 22 2020 an| 04 01 | 2020 M11:30 PM
2LMANNER0FDEATH: UNDETERMINED PENDING 28.WAS CASE
RFEREED TO 29AAUTDPSY† l 298.IF Yi5,WERE USED
FINOlNGSTODETERMINE
NATURALCAUSE ACCIDENT INVESTIGATIONCORONER
HDMICIDESUICIDE(IRCOMSTANCES ORMEDICALEXAMINERTNO YESREFUSED I CALFSE
DFDEATH?
2 O3 Od 5 6 0 NO 1 YES O O I O2 O NO 1OYES
CONFIDENTIAL SEEINSTRUCTIDM
GHEETFORCOMPLETING OFDEATH
CAUSE CONFIDENTtAl.
30.DEATHWAS
CAUSEC
BY:(ENTER
ONLY
CNCAtlSE
PER
LINE
FOR
(A).(8 ANDC
PARI CAUSE:
I.IMMEDIATE I
1 rninute
DllETOOR ASACONSEQUENCE
DF
(8)COVID-19 Infection 1 week
DLIETODRASACONSE0JENCEOF
(ciacute hypoxic respiratory faWure I1 week
PART It CTHER
SIGNIFICANT
CONDCTIONS
CONTRIBUTING
TO DDTOBACCO TOOEATH?
CONTRIBLITE
IJSE
DEATH
BljTNOT
RELATED
TOCAllSE
GIVEN I (A):«
INPART On 0 N01 YES2 PROBABLY 3M UNKNOWN
FIN RY.
DAT HOUR: 31B. RYLOCALITY:
IMJ'J asarrrandreunly
(Cily ad sate) 31C. INJURY
DESCRIBE
HDW OCURRED 310.P.ACE
CFINJURY: ATWUHK7
31EINJURY
DECECEN- 0F0ELNERY:
IFTRANSPORTATIOT
31F. SPECIFY:32.WAS
InLluRY, 33AIFFEMALE DATE
33B.
,o-- 2o- 3one-n NDsPITALIZED
LAST
l# NO YES o01stpugwe
2MONDS7
waNa
hup me ardem 2
1 Pmpunt Nat tuit
pregmat
pregrunt. ordust
wi0nGdubs
0 1 30 Mmput asmnnGWEbelm sa 4 Unm omnmuswr
Document Filed Date
February 01, 2021
Case Filing Date
December 31, 2019
Category
Torts - Motor Vehicle
Status
Stayed-Court Date/Application Pending
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FILED: NASSAU COUNTY CLERK 02/01/2021 01:27 PM INDEX NO. 618235/2019 NYSCEF DOC. NO. 19 RECEIVED NYSCEF: 02/01/2021 Ex "A" FILED: NASSAU COUNTY CLERK 02/01/2021 01:27 PM INDEX NO. 618235/2019 DOH-1951 NYSCEF RECORDED DOC. NO. (B2011) 19DISTR1CT NEWYORK STATE RECEIVED NYSCEF: 02/01/2021 2952 DEPARTMENTOFHEALTH """" "" 131-2020-00028223 656 CERTIFICATE OF DEATH STATE FILE NUMBER FIRST 1.NAME: MIDDLE LAST 2.SElt OFDEATH: 3A.DA*E I 38.l•0UR: MALE FEMLE MONE 0AY YEAR I Approx Ashok Kumar 1 D2 04 01 2020 | 11:30 PM 0FDEAm:NCSP ¾ PLACE TAL HOSPITAL HOSP1TAL MURSINGPWAFc HOSPICE OTHER 4B.IFFAC1LP.. DATEADMITTE0 neckone) DCAER DUTPATIENT INPATIENTHOME RESIDENEFACILITY(SuciM. MONTH DAY VFAR O o O o o o o 03 21 ] 2020 OFFACIllTY: 4C.NAME UT giveMGren) nodaciEly, I 4D.LOCALITY: (Check ontaMspecM I CECOUNTY 0FDEATit I CITYVILLAGE TOWN Plainview Hospital | O O O Oyster Bay Town |Nassau $TITUTION? citycrton emmty MtiMwname, (r!yeLspecify ad state) ND YES I 0FBIRTH: 6.DATE m I 68.If UNDER 5AAGE 1Y{AR I $6,(FUNDER 1DAV I 7A.CITY MD5TATE yad I 7B,If AGE 0FBIR'ItiffnotUSACoutr UNIRR 1YEAR, CFHOSPITAL NAME OF YEARSI ENTER I ENTER1 I Repy/Presee | BIRW NCIITH DAY VFAR mones ms I hars. rnine I . &SEWEDINLl.S. FGRCE52 ARMED (Sprdyyearsi 9.DECEDENT CFHISPAMC avewee- " - " -state ORIGIM½ectnmeevesthebes½smen•urkemedecewa5rassrHrsumen.uac 10.DECEDENTS RACE wMr me m anmmrmerorNruere A No. naiSpanish.%ssamc/Laimo B Yes. MtxCM Mex.cm. Arrentart CEcarg A] Wehcam B Blad or IridiarlD] Caritse AmentarlC Agim O 1 C Yes.PumRai D Yes,C n Filipino f Jappege G Korea H] htnarme E 01A!r Spanigh/Higppic/Luira i5pec -1 Guamarän erÇnamorroM $gmcan () C d NkrPWess'deurtedshirhrsfdepwar 11.DECEDENT3EDUCATEDN Wpp#. evyMsweprg41pø#sqSmp R American lariaorAlaska Naine (spsdy) grade S8th 2 frthd26 gf a de. no dders 3 Hghs ch as raduate GED P Other Ashr{speedp R Other PachtWIacerspeMyl Somecolege Ipul credpl. nodegree5 AssacMe's degree 6 Bachelor sdegree 7O wamismree aO Decw:WPdess.onCeget 12.50CIALSECuniTT huusEn: 13,MARITAL STATLIS: 14.SURVEVING SPCIN: •• 68 ME9ER MARRIEDMARRIEDWIDOWEC DIVDRCEDSEPARAFED EmerDirthname9spouse 954 O 1 2 o 3 O a O s "'"®"®™"" Kanta Rani 1stusuaLoCCUPATICNabøe OFBUSINESS0R 158KIND INDUSTRY: ' 15C. NAMEAND I.0CAL IIYCE FIRM CCMPANY OR raimr) Ù Taxi Driver |Taxi Self Employed tili RESIDENCE: 168, ComcrRegion/Promot 15C. (Check LCCAllTY: orne adspedly) ' 16fJF CITY ORVILLAGEJS RESIDENCE (SinorCoavrry nat SA- CLTY VILLAGETOWN ' WITHIN ORVILLAGE CITY LIMITS† IF SPECWDWN: Z NY Nassau O O O Oyster Bay Town | OYESDNO AD. 160. STREET ANDNUMBEROFRESIDENCE: I 165. ZIPCCDE: 11801 FERS- MI LAST NAME0F U.BIRTH FIST MI LAST 16.DIRTH NAME0F FATHER / PARENT: MOTHER / PARENT: Raundi Lal Santosh Rani 0FINFORMArE ISA.NAME 96.MA).WG ADDRESS: findu¢tlip codel Kanta Rani Hicksville Hamlet, NY 11801 20A.1 2 REMATION OSWRIAL aCIf0LD5ODOMATION2DB. 3OREkDYAL PJCEOF8URIAL CREMATION. OROTHER REMOVAL I 200.LCCATION: DISPOSITlDN. crtomand (City state) MONTH DAY YEAR 04 06 2020 Nassau Suffolk Crematory Lake Pen nh Hamlet, New York 21ANAhE ANDADDRESS HGME- 3FFUNERAL 21BJEGISIrwiün munn: MOloney's Lake Funeral Home & Cremation Center 218 132 RGif .Aú.na Avenue, Lake PW'±r Harolet, NY 11779 22ANAME0F FUNERAL DIRECTOR: 0F NERAL 2281515NAÏÜfE OlRiCTOR REGISIRAÏÏ0NNÙMBER: 22C. Lauren Lombardi LauranLombardi£&amricaKy Sigmd 14740 OFREGISTRAR: SIGNATURE 23A. I 23B, FILID: DATE I 24A. ORREMOVAL BURLAL PERMIT ISSUED BY: I 248.DATE IS$JED: vokTH CAY YFAR I MDNTH DAY WAil ITEMS25TilRLI35COMP LETED BYCEATIFYlNGPHY -- OR- Curiú•i-Gu•«ER's PHYSICIAN SICIAN ORMEDICAL EXAMINER 25A.CERTIFICATION: Tothebestof my knowledge,deathoccurredatthetime,dateard placeancdueto thecausesstated. Name: Carliners UcenseAro Signanf re: yart.7ames htn&tDO Manih cay Year Ryan James Pamell, DO 285620 £&am,s-,gy gged 04 05 2020 Cerwier STide:O AL1ending PhysicianO Physician acting PhysicianMffefr ofAltending onbehaH 10 coroner 2O Medical Exarniner / Deputy Exitmjrier Medical 888 Old Country Rd, Oyster Bay Town, NY 11803 258.11coroner enter isnotaphyssrilp. CorowsPhysidani mnle&litle Ucense ho.: Signarwe h*L | | 25C.IIcatlier isnotattsading physicim. enter Physient Attending name &title UmseNo.. Mdrost physiri 26AAttending Mem- cu wr som car agia Mom Dgy Ye:1 260,Pro Man9 Day Veg Tim deceased: 03 attended byattendinochysicia D"' mu| | 22 2020 04 | 01 | 2020 | 03 | 22 2020 an| 04 01 | 2020 M11:30 PM 2LMANNER0FDEATH: UNDETERMINED PENDING 28.WAS CASE RFEREED TO 29AAUTDPSY† l 298.IF Yi5,WERE USED FINOlNGSTODETERMINE NATURALCAUSE ACCIDENT INVESTIGATIONCORONER HDMICIDESUICIDE(IRCOMSTANCES ORMEDICALEXAMINERTNO YESREFUSED I CALFSE DFDEATH? 2 O3 Od 5 6 0 NO 1 YES O O I O2 O NO 1OYES CONFIDENTIAL SEEINSTRUCTIDM GHEETFORCOMPLETING OFDEATH CAUSE CONFIDENTtAl. 30.DEATHWAS CAUSEC BY:(ENTER ONLY CNCAtlSE PER LINE FOR (A).(8 ANDC PARI CAUSE: I.IMMEDIATE I 1 rninute DllETOOR ASACONSEQUENCE DF (8)COVID-19 Infection 1 week DLIETODRASACONSE0JENCEOF (ciacute hypoxic respiratory faWure I1 week PART It CTHER SIGNIFICANT CONDCTIONS CONTRIBUTING TO DDTOBACCO TOOEATH? CONTRIBLITE IJSE DEATH BljTNOT RELATED TOCAllSE GIVEN I (A):« INPART On 0 N01 YES2 PROBABLY 3M UNKNOWN FIN RY. DAT HOUR: 31B. RYLOCALITY: IMJ'J asarrrandreunly (Cily ad sate) 31C. INJURY DESCRIBE HDW OCURRED 310.P.ACE CFINJURY: ATWUHK7 31EINJURY DECECEN- 0F0ELNERY: IFTRANSPORTATIOT 31F. SPECIFY:32.WAS InLluRY, 33AIFFEMALE DATE 33B. ,o-- 2o- 3one-n NDsPITALIZED LAST l# NO YES o01stpugwe 2MONDS7 waNa hup me ardem 2 1 Pmpunt Nat tuit pregmat pregrunt. ordust wi0nGdubs 0 1 30 Mmput asmnnGWEbelm sa 4 Unm omnmuswr