Trop, Hyman STATE OF VERMONT DEPARTMENT OF HEALTH Division of Vital Statistics
ID /BURIAL. IT PERMIT Burial Permit No.
Full name of decease ' >m/9 ' k..
ili—
a a Place of death..._ o - L 6' t'1 � 0
14 �0 'j� (Town or City) (count _� (S )
Egd Date of death (/ ''_ ._ �,z ._' 19. Color Sex... . --( Agp ‘'6 `
a w q Method of disposal _ �� 'e�f C�/C'i!1 /�E
a q r+ (B 1, remation, si,Sto eta) (Cemetery or Cremat ( 3)) tate)
W t7 "" li$ Funeral Director ` `i`- II9 be `.. Addres �' { C.'- �
WZlz" ° PERMIT
zE2q- O rI
p G A cer• .. th•awing been fi . as,a quire -the laws of the State of Vermont, permi gon in kereby given to
a W Z`Z$ III ./ (% - _ "'to dispose of th> body as ab,ve stated.
( uneral ctor ,v as Su I ,-
C I Dated at .. this-.'-- r 19 .L
(Clerk's Address) "
:' a e'/
'fi w
i. (Town or City Clerk)
i.-0 C '�`''�`ETE Y OR CREMATORY AUTHORITY SHALL ILL OUT CE BELOW
Body was on ..�-....$-.. 19_.�...�._ in ..........._.. u" a,(cr.wated, Bar' Storerk eta) , . , (Cemetery or Crematory)
Place - `.'�,.._. . ___ u=r Signature_.___.k=g '+"--
--
(Sexton or Person in Charge)
SEE OTHER SIDE
%READ CAREFULLY •
TOWN OR CITY CLERK: This ;Y'al-transit permit may be issued only upon receipt of a death
certificate. In special emergencies, tel- '`one the Department of Health for instructions,''
FUNERAL DIRECTORS: The bu'r'i-transit permit is required for any manner of disposition of a
dead body including interment, storage, ; ation and transportation. A permit is required for each
stillbirth before disposal of the body.
When used as a transit permit for t iso tion by common carrier,this permit or a duplicate thereof
should be enclosed in a strong envelope 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 ►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 o vault is located,
properly certified, according to the provistons 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