Bouton, Courtney MISSOURI DEPARTMENT OF HEALTH
-. BUREAU OF VITAL RECORDS
<i� OUT-OF-STATE DISPOSITION NOTIFICATION/AUTHORIZATION
This notification is to be used only when deemed necessary by Funeral Home Licensee.
The State of Missouri no longer requires the acquisition of a permit prior to disposition of a dead body, effective August 13,
1984. Authorization for disposition is acquired through notification of death to the Local Registrar in the county which the
death occurred.
Section 193.175, RSMo(1986)
I HEREBY CERTIFY THAT NOTIFICATION OF DEATH FOR
DECEDENT
Courtney E. Bouton WAS FILED WITH THE LOCAL REGISTRAR OF
COUNTY DATE FILED BY LOCAL REGISTRAR(MONTH,DAY,YEAR)
St. Charles , MISSOURI ON 08/15/2014
CEMETERY OR CREMATORY-NAME LOCATION (CITY,STATE) DATE(MONTH,DAY,YEAR)
Pineview Crematory Queensbury,New York
SIGNATU E (FUNE HOME LICENSEE) MO.LICENSE NUMBER
2013005495
MO 580-0727(10-92) AN EQUAL OPPORTUNITY/AFFIRMATIVE ACTION EMPLOYER-services provided on a nondiscriminatory basis VS-302(10-92)