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VanGuilder, Rita Louise 1E-: NEW YORK STATE DEPARTMENT OF HEALTH Burial - Transit Permit Bureau of Vital Records Name First Middle Last Sex Rita Louise Van Guilder Female Date of Death Age If Veteran of U.S.Armed Forces, 03/19/2023 78 Years War or Dates l`• Place of Death Hospital,Institution or WCity,Town or Village Moreau Town Street Address 7 Fuller Road, Moreau Town,New York 12803 p Manner of Death 111 Natural Cause Accident iii Homicide []Suicide nUndetemined n Pending W E.) Circumstances Investigation WG Medical Certifier Name Title John Stoutenburg MD Address 100 Park St,Glens Falls,New York 12801 Death Certificate Filed Town Of Moreau District Number Register Number City,Town or Village 4562 17 ©Burial Date Cemetery,Crematory or Facility Name 03/24/2023 Pine View Cemetery Entombment Address Cremation Queensbury Town,New York ElDonation Date Place Removed ❑Removal and/or Held H and/or N Hold Address 0 Q. Date Point of U)❑Transportation Shipment 0 by Common Carrier Destination Date Cemetery Address Disinterment Date Cemetery Address Reinterment Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-South Glens Falls 01078 Address 136 Main St,S Glens Falls,New York 12803 Name of Funeral Firm Making Disposition or to Whom -. Remains are Shipped,If Other than Above 2 Address It W Ct" Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 03/22/2023 Registrar of Vital Statistics Brenda Rutter(Electronically Signed) (signature) District Number 4562 Place Town Of Moreau I certify that the remains of the decedent identified above were disposed of in accordance with this permiter . oonn:I— A ,`�. , \' W Date of Disposition ,,944,95 Place of Disposition .i2f wUl k 'i /?L U j cr 1 � �V�/ / 4 �' (address) W L_.J�'/6 gI E c2 in (section) ` (tot numb r) (grave number) 8 Name of Sexton or Person in Charge of Premises LG/Y)/& 761ec- e (please print)Z r W Signature Title J/i .. �/n 7-' -r� DOH-1555(07/18)p 1 of 2 Public Health Law Sec. 4145(2b) Receipt Human remains of ' delivered on .`r - , 20 `1.3 i Pine View Cemetery Representing the funeral home named on burial permit Official Funeral Directors Reg.or License# VAnGuilAper Queensburv. NY „- i LIC: Lot No. 29E Address 477 Uppper Sherman AvenueSection NO•Erie Owner Alfred and Rita VanGuilder Plot Erie Date Nov_ 13, 2013 67 Superficial ft. @ LocationBounded West by Wetmore, North vacant. East vacant, South Vacant Corner Posts Remarks 518-793-2858 Deed No. (and changes) 3832 Payment Record Paid j,u, _nal chpric # 4305 . recetpt # 01)8281 LOT' , , I Record of Interments b.‘"D• to-6'.(D1 _ I / .iail( .i;)cic.Q. )0.8. VA 1 1 2 4-4‘i\--CitnCtiN\--- $2._ 5 aLi.W c.)(:)-- iil "c9-',?/' 1 \I , 3 1 , t ; 4 C oi 1 1 J i 1 I _ F i EL S 1 ‘I i c2 ' i 1 i V/LI `I 1 a i --- Form No. 01 VANGUILDER NAME Rita VanGuilder Age: 78 Lot Owner: Alfred & Rita VanGuilder Lot# Erie 29E Grave# 2 Case: Concrete Died: 3.1 9.2 3 Interred: 3 .2 4 .2 3 Funeral Home: Kilmer Cemetery: Pine View