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Poulos, Tony James NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Tony James Poulos Male Date of Death Age If Veteran of U.S.Armed Forces, 03/24/2021 92 Years War or Dates Army Place of Death Hospital,Institution or WCity,Town or Village Queensbury Town Street Address 11 Orchard Drive,Queensbury Town, New York 12804 ,p Manner of Death ❑X Natural Cause Accident ElHomicide 1=1 Suicide ❑Undetermined ❑Pending Circumstances Investigation WG Medical Certifier Name Title Anthony Petracca MD Address 3 Irongate Center,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Queensbury 5657 79 ©Burial Date Cemetery,Crematory or Facility Name 03/29/2021 Pine View Cemetery Entombment Address ▪Cremation Queensbury,New York ❑Donation Removal Date Place Removed and/or and/or Held N Hold Address 0 a Date Point of (/) ❑Transportation p by Common Shipment Carrier Destination Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Regan Denny Stafford Funeral Home 01443 Address 53 Quaker Rd,Queensbury,New York 12804 Name of Funeral Firm Making Disposition or to Whom I— Remains are Shipped,If Other than Above Address 2 W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/26/2021 Registrar of Vital Statistics Carnrnexlrlegard Bar6ergkctrourca11:y Signed) (signature) District Number 5657 Place Queensbury, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: IH W Date of Disposition 3/29/2021 Place of Disposition 21 Quaker Rd_ Queenbsury, NY 12804 2 (address) W 11 C Huron 1 N (section) (lot number) (grave number) GName of Sexto r Person in Charge es Connie Goedert (please print) W Signature iti ae___ Title Superintendent DOH-1555(07/18)p 1 of 2 Public Health Law Sec.4145(2b) ii 128 4 IReceipt Human remains of 1(,_•)1:.- ,-), i .4 delivered on ' -,T ',- '--- 1 , 20 z i I ' -- I 1 „,,./ e,-;//7-e" ,----_ ' .. .. - , Pine View Cemetery Official Representing the funeral home named on burial permit Funeral Directors Reg.or License# ' .....\.:•,,, , I POULOS NAME Tony J. Poulos Age: 92 Lot Owner: Tony J Poulos Lot# Huron 1 1 C Grave# 1 Case: Concrete Died: 3/2 4/2 0 21 Interred: 3/2 9/2 0 21 Funeral Home: Regan Denny Stafford FH Cemetery: Pine View