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Cummings Jr., Richard Edward li —)11.o • NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Richard Edward Cummings Jr. Male Date of Death Age If Veteran of U.S.Armed Forces, 09/01/2021 60 Years War or Dates 1979-1983 F Place of Death Hospital,Institution or W City,Town or Village Glens Falls Street Address Glens Falls Hospital O Manner of Death 0 Natural Cause 0 Accident El Homicide El Suicide El Undetermined Pending ILLI Circumstances Investigation W Medical Certifier Name Title © Shahid Ahmed MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 375 Burial Date Cemetery,Crematory or Facility Name 09/03/2021 Pine View Crematory • Entombment Address 0 Cremation Queensbury Town,New York Donation Z• El Removal Date Place Removed and/or and/or Held N Hold Address 0 A. Date Point of N ❑Transportation ES by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Maynard D Baker Funeral Home 01130 Address 11 Lafayette St,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom E— Remains are Shipped,If Other than Above 2 Address CC W Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 09/03/2021 Registrar of Vital Statistics 1o6ertf7 �rewCurtrs Yctronica'Sgned (signature) District Number 5601 Place Glens Falls, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z .- 1 W Date of Disposition q 131 Z' Place of Disposition a 2 (address) WCC. (section) (lot number) (grave number) A1 gName of Sexton or Person in Charge of Premi s el4 ., Z (plea print) W Signature Title /i 4Tbkt DOH-1555(07/18)p 1 of 2 1. Public Health Law Sec. 4145(2b) 151 Receipt t Human remains of n .t L.,, delivered on 20 1 r Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# i