Otruba, Nora Jacquelyn @ - . # /001
NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit
Bureau of Vital Records
Name First Middle Last Sex
Nora Jacquelyn Otruba Female
Date of Death Age If Veteran of U.S.Armed Forces,
12/17/2022 88 Years War or Dates
Place of Death Hospital,Institution or
ZCity,Town or Village Johnsburg Town Street Address Elderwood at North Creek
pManner of Death Ei Natural Cause ❑Accident Ei Homicide OSuicide riUndetermined ElPending
W Circumstances Investigation
W Medical Certifier Name Title
0 Jennifer Donovan DO
Address
112 Ski Bowl Rd,Johnsburg Town,New York 12853
Death Certificate Filed Town Of Johnsburg District Number Register Number
,Town or Village Cie 5655 33
Burial Date Cemetery,Crematory or Facility Name
12/20/2022 Pine View Crematorium
Entombment Address
Cremation Queensbury Town,New York
0Donation
0 GI Removal Date Place Removed
- and/or and/or Held
F-- Hold Address
CO
0
0. Date Point of
N❑Transportation Shipment
5 by Common
Carrier Destination
Disinterment Date Cemetery Address
Reinterment 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
1— Remains are Shipped,If Other than Above
a Address
C
W
0' Permission is hereby granted to dispose of the human remains described above as indicated.
Date Issued 12/19/2022 Registrar of Vital Statistics Jean M Comstack(E(ectronicaQy Signed)
(signature)
District Number 5655 Place Town Of Johnsburg
I certify that the remains of the decedent identified above were disposed of in accordance with this permit on:
WDate of Disposition 12I ti�TZ Place of Disposition ,t lL
2 (address)
W
Cle (section) (lot num (grave number)
gName of Sexton or Person in Charge of Pre 's A", s 1�
Ip/ease print
W Signature Title r' /n T�
DOH-1555(07/18)p 1 of 2
4 t
I P I
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#