Otruba, Jeremy NEW YORK STATE DEPARTMENT OF HEALTH -,� `f c3
Vital Records Section Burial - Transit Permit
.. Name First Middle Last Sex
.k' Jeremy Daniel Otruba Male
-4- Date of Death Age If Veteran of U.S. Armed Forces,
January 22, 2015 26 War or Dates
,„, Place of Death Hospital, Institution or
City, Town or Village Moreau Street Address
Manner of Death❑ Natural Cause X❑ Accident 0 Homicide ❑ Suicide ❑ Undetermined ❑ Pending
Circumstances Investigation
' Medical Certifier Name Title
'' Michael Sikirica,
is Address
50 Broad Street Waterford, NY 12188
Death Certificate Filed District Number Register Number q
City, Town or Village Moreau o�
❑Burial Date Cemetery or Crematory
January 26, 2015 Pine View Crematory
❑Entombment Address
®Cremation Quaker Road Queensbury,NY 12804
Date I Place Removed
❑ Removal I and/or Held
and/or Address
` Hold
Date Point of
❑Transportation Shipment
by Common Destination
?': Carrier
❑ Disinterment
Date Cemetery Address
_!❑ Reinterment Date Cemetery Address
it" Permit Issued to Registration Number
r Name of Funeral Home M.B. Kilmer Funeral Home 01078
;:i:' Address
136 Main Street, South Glens Falls NY 12803
`-' Name of Funeral Firm Making Disposition or to Whom
Remains are Shipped, If Other than Above
Address
Permission is hereby granted to dispose of the human ream$descri ed above as indicated.
er
` ' Date Issued //d /c)O/5 Registrar of Vital Statistics kazo...if
_� (signature)
District Number Place i f kin. 0 t tf irQ, � er o/ds d 7a2y/NV mD?
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
- Date of Disposition 01/26/2015 Place of Disposition Quaker Road Queensbury,NY 12804
(address)
.. (section) A (lot number) (grave number)
Name of Sexton or Person in Charge f Premises
(L Seni (
dI
lease print)
Signature Title 4+
(over)
DOH-1555 (02/2004)