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Rouillard, Dorothy Cowles NEW YORKSTATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Dorothy Cowles Rouillard Female Date of Death Age If Veteran of U.S.Armed Forces, 05/06/2020 91 Years War or Dates Place of Death Hospital,Institution or WCity,Town or Village Fort Edward Town Street Address Fort Hudson Nursing Center Inc p Mannerof Death ©Natural Cause Accident Homicide Suicide ❑Undetermined Pending W V Circumstances Investigation UJ Medical Certifier Name Title John Quaresima MD Address 319 Broadway,Fort Edward Town,New York 12828 Death Certificate Filed District Number Register Number City,Town or Village Fort Edward 5755 45 Burial Date Cemetery,Crematory or Facility Name 05/08/2020 Pine View Crematorium Entombment Address PflCremation Queensbury Town,New York Donation Z Date Place Removed O Removal P and/or and/or Held N Hold Address O CL U Transportation Date Point of p by Common Shipment Carrier Destination Disinterment Date Cemetery Address pi Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home Carleton Funeral Home Inc 00281 Address 68 Main Street,P.O.Box 67, Hudson Falls,New York 12839 Name of Funeral Firm Making Disposition orto Whom E Remains are Shipped,If Other than Above Address W tZ Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 05/08/2020 Registrar of Vital Statistics Aimee Mahoney(ECectronica!!y Signed) /signature/ District Number 5755 Place Fort Edward, New York I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: H Z Date of Disposition S^/2-20W Place of Disposition f Q W 2 Jaddre / W to cc (section) (lot number) (grave number/ 0 Name of Sexton or Person i har f Premises �Lvkki Z /please print/ W Signature Title DOH-1555(07/18)p 1 of 2 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#