Williams, Veronica DH-PHS-BTP-89a VERMONT DEPARTMENT OF HEALTH
BURIAL-TRANSIT PERMIT Permit No.
Permit for Removal, Disinterment and Reinterment
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1. Decedent's Name(first, middle, last 2. Sex 3. Date of Death
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P 4. Cit frown f Death 5. Date of Birth 6. ace of Birth
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7. Na a and ddr s of F eral rector or Authorized Person
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PERMISSION REQUESTED FOR: (Check only one box and complete ap ropriate section)
El Temporary E Removal from - remation ❑Burial or
0 Storage Temp. Storage or (Section C) Entombment
(Section A) Disinterment
(Section B) (Section D)
SECTION A: (If temporary storage. complete this section.)
Place of Storage(Name of Cemetery or Vault) City/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION B: (If removal from temporary storage or disinterment. complete this section.)
Name of Cemetery or Vault from which body is being removed City/Town Date
Name of Cemetery where body is being taken City/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION C: (Complete this section if body will be cremated.)Naa of Crem,,att�rium /" City/Town, State / Date (� n�
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0 PERMISSION IS GIVEN TO DISPOSE OF S BODY AS STATED ABOVE. (Title 18, V.S.A. 5201)
Si nature of Clerkpput City/Town Date
Signat►ebf Crematorium Official Container Number Date
SECTION D: (Complete this section if body/cemains will be buried or entombed.)
Name of Cemetery City/Town Date
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PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Body/Cremains were ❑Buried ❑Entombed Date
Name of Cemetery, Section Lot Number Grave Number
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City/Town, State Signature-o Sexton/Cem tery Official
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This permit is to be filed with the City/Town Clerk by the 10th day of the month following disposition. (Title 18, V.S.A. 5215)