Loading...
Poulos, Gus Thomas Cit F 13- 23z. NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Gus Thomas Poulos Male Date of Death Age If Veteran of U.S.Armed Forces, 02/28/2024 66 Years War or Dates Place of Death Hospital,Institution or Z City,Town or Village Albany Street Address Albany Medical Center Hospital • Manner of Death Undetermined Pending Natural Cause Accident Homicide Suicide g tL Circumstances Investigation C.) Medical Certifier Name Title O Peter Pevzner Address 43 New Scotland Ave,Albany,New York 12208 Death Certificate Filed City Of Albany District Number Register Number City,Town or Village 0101 0527 Burial Date Cemetery,Crematory or Facility Name 03/04/2024 Pine view crematory Entombment Address ©Cremation Queensbury Town,New York Donation ZZ❑Removal Date Place Removed and/or and/or Held H Hold Address 0 d Date Point of (/)❑Transportation p by Common Shipment Carrier Destination O Disinterment Date Cemetery Address O Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Fort Edward 01079 Address 82 Broadway, Fort Edward, New York 12828 Name of Funeral Firm Making Disposition or to Whom 1— Remains are Shipped,If Other than Above .S Address CC W n' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/04/2024 Registrar of Vital Statistics Kerry Bartko(omew(ECectronica(CySigned) (signature) District Number 0101 Place City Of Albany I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: I- Z Date of Disposition 3) 5 I Z(4 Place of Disposition ' '3t i 4 1 G , 10 2 (address) W CC N (section) (lot nu r (grave number) /1 • Name of Sexton or Person in Charge of P7ise r7 1 Z (lease p L!J Signature Title ` i ,ni DOH-1555(07/18)p 1 of 2 :1 . C.: :� 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#