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Rouse, Carol Ann NEW YORK STATE DEPARTMENT OF HEALTH Bureau of VitaL Records Burial - Transit Permit Name First Middle Last Sex Carol Ann Rouse Female Date of Death Age If Veteran of U.S.Armed Forces, 01/03/2024 77 Years War or Dates Place of Death Hospital,Institution or W City,Town or Village Argyle Village Street Address 17 Elm Street,Argyle Village,New York 12809 Manner of Death El Natural Cause EAccident Homicide Duicide Undetermined Pending W Circumstances Investigation W Medical Certifier Name Title Mark Quaresima MD Address 9 Carey Road,Queensbury Town,New York 12804 Death Certificate Filed Town Of Argyle District Number Register Number City,Town or Village 5750 2 Burial Date Cemetery,Crematory or Facility Name 01/05/2024 Pine View Crematory Entombment Address ©Cremation Queensbury Town,New York Donation ❑Removal Date Place Removed and/or and/or Held Hold Address N 0 0- Date Point of U)❑Transportation p by Common Shipment Carrier Destination O Disinterment Date Cemetery Address Reinterment Date Cemetery Address Permit Issued to Registration Number Name of Funeral Home M B Kilmer Funeral Home-Argyle 01077 Address 123 Main St,Argyle,New York 12809 Name of Funeral Firm Making Disposition or to Whom F_ Remains are Shipped,If Other than Above 2 Address CC W a' Permission is hereby granted to dispose of the human remains described above as indicated. Date Issued 01/04/2024 Registrar of Vital Statistics She(Cey 5M2ckernon(ECectronicaffy Signed) (signature) District Number 5750 Place Town Of Argyle I certify that the remains of the decedent identified above were disposed of in accordance with this permit on: Z Date of Disposition / e ieZ'/ Place of Disposition (address) W CC CC (section) (lot (grave number) Name of Sexton or Person in Charge of Premi es ) i4Yt/7O e) ci Z (please print) tL Signature Title GPS DOH-1555(07/18)pi 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#