Chambers, Walter STATE OF VERMONT DEPARTMENT OF HEALTH Division of Vital Statistics
BURIAL--TRANSIT PERMIT Burial Permit No._........r..:::.........._._._.
Full name of deceased 1 Aattris•
re .2 Place of death ._. f i ..._ _.. `(��o_,2ia.C�t� �t __.._ _._.�,
0 E (Town or City) •un ) (State)
Li. x ax Date of death _...._.. ._. 19a�._ Color
a F Sex-ra __ Age71-7~
s (Yr• Mo., Da.)
a NE �qy Method of disposal ._ �...,v ',pi.-; _ _- c.�.ta..s •4 - a/
p; Z 0.0 (Burial, Cremati�r,Trgnsitt Storage,etc.) (Cemetery ., Crem_ ry) n , 071:13. .is)/! _
kic,1>. " 6.2 Funeral Director _ 0, -ty `:. .._._ _,�.._.._...___...._.... Address' 9 s
xa ..a p ! PERMIT
z Z 4 e A A certificate of death havingb: n filed as required bythe laws of the State of Vermont,...IAA.w qpermission is hereby given to
( W z 2 e _..... ..__... .__.._ •.» • ____._......._._..__ __._._ to dispose of the body as above stated.
a f.,_^~ (Funera W irec Mor or Person Acting as Such)
pd Dated at _...._....._._.:t. . this I R�.'tct- ._...._ day of ___..19.>�..�
ci) „3 a (Clerk's Address) , .� � _
e Signatur�C -.�_. ._ 71. in a _ :__ _
;p (Town or City Clerk)
[." CEMETERY_4R CREMATORY AUTHORITY SHALL, FILVOUT SPACE BELOW
Body was /�t �4/1-c> _.._ . on t :�..._ 4--Z- -
, Due+ed,Stated,eye}j 19�r..._ in(l' .tw.-
�� (Ce teat' or Crema ry) __.___
Place _�,�:- .. _ .� �� _ Signature .. t9r_a� .�'�._ ...__....�. -� ..t..Z _—
may_ (Sexton or Person in Charge)
READ CAREFULLY
TOWN OR CITY CLERK: This burial-transit permit may be issued only upon receipt of a death
certificate. In special emergencies, telephone the Department of Health for instructions.
FUNERAL DIRECTORS: The burial-transit permit is required for any manner of disposition of a
dead body including interment, storage, cremation and transportation. A permit is required for each
stillbirth before disposal of the body.
When used as a transit permit for transportation by common carrier, this permit or a duplicate thereof
should be enclosed in a strong envelope and attached to the shipping case. A separate permit is required
for disinterment and reinterment.
SEXTON: It is unlawful for any sexton, or other person in charge of a burial place, to permit burial
or other disposition of a dead body before a burial-transit permit is deposited with him. (The sexton may
accept the permit of any state or of the District of Columbia as authorization for burial.)
All permits must be delivered to the clerk of the town in which the cemetery, tomb or vault is located,
properly certified, according to the provisions of Section 4152, Vermont Statutes, Revision of 1947.
PENALTY for violation is not more than $500 or less than $20.
DH-35-20M-4-50