Cassin, Joseph DH-PHS-BTP-89a VERMONTEPARTMENT OF HEALTH A—
BURIAL-TRANSIT PERMIT Permit No. �o
Permit for Removal, Disinterment and Reinterment
1. Deceder ' Nam (first, midge, last) 2. Sex 3. Date of Death
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4. City/Town of Death 5�f ate of Birth 6. Place of Birth
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7e and Address of Funeral Dire or or Auth ized Person
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PERMISSION REQUESTED FOR:(Check only one box and complete appropriate section)
❑Temporary ❑Removal from remation ❑Burial or
Storage Temp. Storage or Section C) Entombment
(Section A) Disinterment (Section D)
0 (Section B)
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.)
e of Crematorium"?/* Ci /T n,State /� t Dat
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PERMISSION IS GIVE • • SPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A.5201)
ure of Cler puty Ci /To Date
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ign ure emat•4u Official ContairSer Number _ to
SECTION D: (Complete this section if body cremains will be buried or entombed.)
Name of Cemetery City/Town Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
IIISignature of Clerk or Deputy City/Town Date
Body/Cremains were ❑Buried ❑Entombed Date
Name of Cemetery Section Lot Number Grave Number
City/Town, State Signature of Sexton/Cemetery Official
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)