Liberty, Ernest c STATE OF VERMONT DEPARTMENT OF PUBLIC HEALTH
o Division of Vital Statistics
.y
s BURI L—TRANSIT PERMIT Burial Permit No
Q Full name of deceased.__...._ 1 /?�Cc fi
• f
p Place of death._.__ �. r SAL
w' own or City) (County) State)
'4 Date of death__._ ._19.i$... Color Sex ge._ 3_z`r
•E Method of disposal et-e-?::_ _ ... .ir� _ �_._ _ _...._.._...._...._..._.. _.._�f _.
y (Buri�{ ire t: `, transit, storage. etc.) (Cemetery or C toyy) Town) (Sta,
gi Funeral director....._...____ /,e......_ _ —..._. Address
`'�� I
I. ._.
O PERMIT -- —
CL A certificate of death vingb e as required bythe laws of the State of Vermont, permission is hereby
q given to _._.
8 �� �'' to dispose of the body as above stated.
(Funera ect r person acting as suck)
Dated at...._...._..........� .... ......._..._... this yr�...._..._ d y of._..._....�`�..._........._ __19_4 -3
4... (Clerk's Address) _
an
O Signature f..._.
(Town or C:y :erlt)
•E. CEMETERY OR CREMATORY AUTHORITY SHALL FILL OUT SPACE BELOW
a Body was on April s',?.0 1 ..4.3..... in S:t..A4hQns..i@..............._...._...._
(C rat,,i,Luried sty, ..r:`.) Y.Y. O , Cen •y or Crematory)
Place Glens +S`�llf.J Signature.............. "�/�f�
(Sexton or person in charge)
F SEE OTHER SIDE