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NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Joshua W Cummins Male
Date of Death Age If Veteran of U.S.Armed Forces,
05/24/2022 38 Years War or Dates
E. Place of Death Hospital,Institution or
Z City,Town or Village Warrensburg Town Street Address 4112 State 9 Route#4,Warrensburg Town,New York 12885
LUILI
• Manner of Death El Natural Cause Accident illHomicide []Suicide Undetermined Pending
U Circumstances Investigation
WD Medical Certifier Name Title
Connie Goedert Coroner
Address
1400 St Route 9,Lake George Town,New York 12845
Death Certificate Filed Town Of Warrensburg District Number Register Number
City,Town or Village 5660 10
Burial Date Cemetery,Crematory or Facility Name
05/27/2022 Pineview Crematory
Entombment Address
[]Cremation Queensbury Town,New York
DDonation
Z
❑Removal Date Place Removed
and/or and/or Held
F- Hold Address
U)
0
C- Date Point of
N[]Transportation
p by Common Shipment
Carrier Destination
[]Disinterment Date Cemetery Address
Date Cemetery Address
El Reinterment
Permit Issued to Registration Number
Name of Funeral Home Densmore Funeral Home Inc 00448
Address
7 Sherman Ave,Corinth,New York 12822
Name of Funeral Firm Making Disposition or to Whom
1— Remains are Shipped,If Other than Above
N Address
CC
W
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 05/27/2022 Registrar of Vital Statistics Pamela M Lloyd(Electronically Signed)
(signature)
District Number 5660 Place Town Of Warrensburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
IH
Z Date of Disposition CI Zl In Place of Disposition ,t 4� L f-d—..
UJ
2 (address)
W
N CC (section) (lot number) (grave number)
O Name of Sexton or Person in Charge of Premises t►I' LI w11-
Z ( ease print)
tL Signature �/s Title
� �W�
DOH-1555(07/18)p 1 of 2
f t
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20 •
Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License# '