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Ponusky, Robert A
NEW YORK STATE DEPARTMENT OF H EALTH Burial - Transit Permi Bureau of Vital Records Name First Middle Last Sex Robert A. Ponusky Male Date of Death Age If Veteran of U.S.Armed Forces, 11/20/2021 78 Years War or Dates 1960's H Place of Death Hospital,Institution or WCity,Town or Village Glens Falls Street Address Glens Falls Hospital 0 Manner of Death © Natural Cause ❑Accident ❑Homicide ❑Suicide 1:1Undetermined I=1 Pending UCircumstances Investigation WW Medical Certifier Name Title 0 Kyle Leonard MD Address 100 Park St,Glens Falls, New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 531 ❑Burial Date Cemetery,Crematory or Facility Name 11/24/2021 Pine View Crematory El Entombment Address X❑Cremation Queensbury Town,New York ❑Donation 0 ❑Removal Date Place Removed and/or and/or Held H Hold Address N 0 CI. Date Point of (/) ❑Transportation O by Common Shipment Carrier Destination Disinterment Date Cemetery Address El Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Miller Funeral Home 01199 Address 6357 Nys Rte#30, Indian Lake,New York 12842 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above 5 Address CC W a Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 11/23/2021 Registrar of Vital Statistics Robert Andrew Curtis(Electronically Signed) (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: Ih Z Date of Disposition II Izb►t Place of Disposition Rajt..— �.�}at W 2 (address) W CO Q (section) /r (lot number) (grave number) GName of Sexton or Person in Charge of Pre ' es `/MJ t -..� n�it Z /Phase print/ W i...) Signature / Title ( n'"�4J DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) 1 Receipt Human remains of delivered on , 20 Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License#