Cummings, Eugene E. NEWYORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit .
Bureau of Vital Records
Name First Middle Last Sex
Eugene E.Cummings Male
Date of Death Age If Veteran of U.S.Armed Forces,
04/24/2023 80 Years War or Dates
Place of Death Hospital,Institution or
Z City,Town or Village Clifton Park Town Street Address 66 Longview Drive,Clifton Park Town,New York 12065
1p Mannerof Death Natural Cause ❑Accident ❑Homicide Suicide Undetermined ❑Pending
Circumstances Investigation
W Medical Certifier Name Title
Nicholas Fusella DO
Address
i, 2125 River Road,Niskayuna Town,New York 12309
Death Certificate Filed Town Of Clifton Park District Number Register Number
City,Town or Village 4552 62
Burial Date Cemetery,Crematory or Facility Name
— 04/28/2023- --- St.Alphonsus Cemetery
Entombment Address
Cremation Queensbury Town,New York
Donation
0 Date Place Removed
❑Removal
and/or and/or Held
N
Hold Address
O
d Date Point of
Q by Common Shipment
Carrier Destination
Disinterment Date Cemetery Address
Reinterment
Date Cemetery Address
Per Issued to Registration Number
Name of Funeral Home Gordon C Emerick Funeral Home 00676
Address
1550 Route 9,Clifton Park,New York 12065
Name of Funeral Firm Making Disposition orto Whom
f Remains are Shipped,If Otherthan Above
5Z Address
Q
- - - -
a Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 04/27/2023 Registrar of Vital Statistics Teresa Bro6ston(ECectronicaCCy Signer)
(signature)
District Number 4552 Place Town Of Clifton Park
I certify thatthe remains of the decedent identified above were disposed of in accordance with this permit on:
k=
WDate of Disposition Z Place of Disposition _
(addre )
LU
N sec60n) (lot number) (grave number)
cci
0 Name of Sexton or Pers in Charge of Premises
Z (please print)
W Signature Title
DOH-1555(o7/18)p 1 of 2