Cummings, Lorraine NEW YORK STATE DEPARTMENT OF HEALTH` " l'/`q
Vital Records Section Burial - Transit Permit
Name First Middle Last Sex
Lorraine Faith Cummings Female
Date of Death Age If Veteran of U.S. Armed Forces,
02/28/2015 60 years War or Dates
Fr Place of Death Hospital, Institution or
Z City, TovJX/ X Schenectady Street Address Ellis Hospital
0 Manner of Deathh ,pdatural Cause ❑Accident ❑Homicide ❑Suicide ❑Undetermined ❑Pending
la "'Circumstances Investigation
W Medical Certifier Name Title
G Miroslav Vytrisal M D
Address
1101 Nott St, Schenectady, N Y 12308
Death Certificate Filed District Number Register Number
City, To00Q01.1043IX Schenectady 4601 243
❑Burial Date Cemetery or Crematory
03/02/2015 Pine View Crematory
[jEntombment Address
€remation Queensbury, N Y
Date Place Removed
�ri Removal and/or Held
and/or Address
M Hold
Cl)
O Date Point of
ti❑Transportation Shipment
G by Common Destination
Carrier
Q Disinterment Date Cemetery Address
•
Q Reinterment Date Cemetery Address
Permit Issued to Registration Number
Name of Funeral Home Compassionate Funeral Care 00364
Address
402 Maple Avenue, Saratoga Springs, Ny 12866
Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
;; Address
ir
II
,` Permission is hereby granted to dispose of the human remain escribed a)ove as indicated.
Date Issued 03/02/2015 Registrar of Vital Statistics l•,,,? b 1 - 'It t)1`n.-4,
/j i(s gnatture) V
District Number 4601 Place Schenectady (J
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
t i fit/IU Date of Disposition 3/y j/S Place of Disposition , (crrrifQ!'--
E (address)
LU
CC (section) (lot number , (grave number)
a Ca Name of Sexton or Person in Charge of Premises ^'" ra'` �
( ease print)
l SignatureL Title (�7 (1d�,
(over)
DOH-1555 (02/2004)