White, Violet • DH-PHS-35-74 STATE OF VERMONT Permit No. Cq4 7
BURIAL-TRANSIT PERMIT
Permit for Disinterment, Transportation and Reinterment
Full name of deceased Date of death q
1. c ` t�t.� 2. i7-1�"1 j l/6
Color or Race Age Sex Place of death (City or Town) (State)
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PERMISSION RE ESTED FOR:
C BURIAL I I CREMATION n TEMPORA STORAGE n DISINTERMENT
(Complete Item 11 below) (Complete Item 12 below)
7.
Place of dis sition (Cemetery or Crematory) (City or Town) (State)
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Name funeral director Busin ss Address
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1 yl,
e. r/- L 1 1 �sGt /l _ -;
1 to porof a of vault) (City or Town) (State)
storage, e
in this s
S11. 11A 11B 11C
If disinterment, Place of (Cemetery) (City or Town) (State)
complete this original
section: burial or
entomb- 12A 12B 12C
ment (Sexton's Signature) (Date)
12. 12D 12E
PERMISSION IS HEREBY GRANTED TO REMOVE AND DISPOSE OF THE BODY IDENTIFIED ABOVE:
Si ure of I rk or deput City o`p n Date
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13. 1 K f�����i( `�t z X _ 14 �.. �I 15. 7-43-79 ! �J
CEM E Y OR CREMATORY AUTHORITIES SHALL FILL OUT SECTIONS BELOW:
Bod w s: Date Name of cemetery or crematory Section & Lot No.
DRIED 17./ /� 44 18. e.4..„3." � � ft 20. p%7 /
n CREMATED Loca it on City or Town) (State) Signature of Sexton
STORED other person in charge
iatea..e"KAIAA'AlT
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• 16. 21. 22