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Otruba, John
_ 113 NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex John Otruba Male Date of Death Age If Veteran of U.S.Armed Forces, 10/18/2021 88 Years War or Dates F Place of Death Hospital,Institution or Z City,Town or Village Glens Falls Street Address Glens Falls Hospital 'p Manner of Death ©Natural Cause El Accident El Homicide Suicide Undetermined Pending Circumstances Investigation W Medical Certifier Name Title Asim Chaudry MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed District Number Register Number City,Town or Village Glens Falls 5601 456 ElBurial Date Cemetery,Crematory or Facility Name 10/20/2021 Pine View Crematorium EjEntombment Address Cremation Queensbury Hamlet,New York EjDonation Z Removal Date Place Removed and/or and/or Held H Hold Address 0 0. Date Point of Cl) ❑Transportation Shipment p by Common Carrier Destination Disinterment Date Cemetery Address IDReinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Barton-Mcdermott Funeral Home Inc 00141 Address 9 Pine St,Chestertown,New York 12817 Name of Funeral Firm Making Disposition or to Whom l• 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 10/20/2021 Registrar of Vital Statistics Robert Andrew Curtis(ECectronica1ySigned) (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: Date of Disposition I 0/7d l! Place of Disposition i t,r �,� --� (ar`ess) W c (section) a (lot number) (grave number) 8 Name of Sexton or Person in Charge of ises n s �Ifi (pose print) W Signature Title C `�tt ��L DOH-1555(07/18)p 1 of 2 rz, Public Health Law Sec. 4145(2b) Receipt „.: Human remains of delivered on / 20 Pine View Cemetery Representing the funeral home named on,buriat perrnit Official Funeral Directors Reg. or License#