Ives, Elsie DH-PHS-5B-78 STATE OF VERMONT
BURIAL-TRANSIT PERMIT Permit'O
6 r"DECEASED—NAME FIRST MIDDLE LAST SEX DATE OF DEATH(Month,Day,Year)
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RACE—(White,Black, AGE LAST BIRTH- UNDER/YEAR UNDER 1 DAY DATE OF BIRTH COUNTY OF DEATH
American Indian DAY(Years) MOS. DAYS HOURS MIN. (Month,Day,Year)
4 ETC.(Specify) •x...,1 "., 5A r c„ 58 5C 8 1 ? .i'} ?rw. 7A • ., r e et p
CITY,TOWN OF DEATH HOSPITAL OR OTHER INSTITUTION(If not in either, IF OSPi7AL or INSTITUTION
7 gave Street and Number) ❑ Inpat. ❑ ER 0 DOA
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PERMISSION REQUESTED FOR: �t
2 BURIAL 0 CREMATION 0 TEMPORARY STORAGE
(Complete Item I2 hoboo)
8.
PLACE OF DISPOSITION(Cemetery or Crematory) (CITY OR TOWN) (STATE)
s. Pine View Cemetery Glens Palls, New York
NAME OF FUNERAL DIRECTOR BUSINESS ADDRESS
10. C. .A0 Calderwood, Inc. 1t_ Box 415, St. Johnsbury, Vt. 05819
411) .,r"e-,";;,d.°„t.. ,,; nr -i ,. MOOMMPIZAM. rr......, -,..,." ,., .. .:, r,b,r ..n..nnd.w., ., a nN:a:n...
IF TEMPORARY PLACE OF Name of nude} (CITY OR TOWN) (STATE)
STORAGE,FILL STORAGE
IN THIS SECTION:
12. 12A. 126. 12C.
1a,.x„ r-(r agagan a r,.,:„19_aR4 ! Upa.,, RMARO ,1, u,;;l ..,:•."sr, r;E . ,i ._ ,-AM,r ,i m'lr,. �a,,,
PERMISSION IS HEREBY GRANTED TO REMOVE AND DISPOSE OF THE BODY IDENTIFIED ABOVE
Signature of clerk or deputy CITY OR TOWN DATE
y/tp�, � ',1 St. Johnsbury, Vt. Oct. 29, 1980
13 ^�'�' -'C-.rC � 14 15
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ao>tt,: tine.. u.,,.,'� ,-a $,.a„�s,r..� �Kw win f. ,.�a�,�,_wr,.,-i.; wN .v a'r .,»�:^�. a�. ,r. ,��.,2: P�,,,�: k. :,�.. ..r ua 3,n i =r..,h�t�...t�,. �a.,�,��4,�1�.<a�"�+"�y
CEMETERY OR CREMATORY AUTHORITIES SHALL FILL OUT SECTIONS BELOW: ,.y rq
BODY WAS: DATE NAME OF CEMETERY OR CREMATORY SECTION y./ LOT NO. PS
#441
LK BURIED 17 �� 18. tr2'Lt'y. t 19. 20.
LOCATION (CITY OR TOWN) (STATE) SIGNATURE OF SEXTON OR
❑ CREMATED � OTHER PERSON IN CHARGE
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❑ STORED f "�.t 1 ✓ at,.......„1„6.t.„")17 c21. 22. ��ttt