Veghte, Anne DH-PHS-58-78
1111 STATE OF VERMONT
BURIAL-TRANSIT PERMIT Permit No
4/DECEAS
ED—NAME FIRST MIDDLE /LAST SEX DATE`OF DEATH(,Month Day Year)
Year)
1 "‘ ' E' 4,J c f !.-i E-,: 2 I.,� 3 Ft dy jJQ`CRACE—( e,Black, AGE LAST BIRTH UNDER 1 YEAR NDER DAY DATE OF BIRTH COUNTY OF DEATH
American Indian, DAY()ror MOS. DAYS " IOURS MIN. (Mont 1) }p/ f°
4 ETC.(Spenf) € t 1,r 1 i c 5A L t 1,...; 5B 5C 6 `..^ i (// 3 7A /" ',f, / ii 4r
CITY.TOWN OF DEATH HOSPITAL OR OTHER INSTITUTION flf not rah,I ! a IF HOSPITAL or INSTITUTI
g �t,ee((( nd," rt ,( gyp" ❑ Inpat. ❑ ER ❑ I
78 - s ,'ts'"s 7 s�t Ht!tSjl ° "'�. t f'' .+"y`, _,,, 7D
PERMISSION REQUESTED FOR
'- BURIAL CREMATION ❑ TEMPORARY STORAGE
(Complere Item t:helouy
8
PLACE OF DISPOSITION(Cemetery or(re.,weary) (CITY OR TOWN) (STATE)
9 Pine crematory Glens Falls new york
NAME OF FUNERAL DIRECTOR BUSINESS ADDRESS
• ,o Aldous Funeral Home 1, 44 No Main street Rutland, VT 05701
IF TEMPORARY PLACE OF (CITY OR TOWN) (STATE)
STORAGE.FILL STORAGE
IN THIS SECTION
12 12A. 12B. 12C.
PERMISSION IS HEREBY GRANTED TO REMOVE AND DISPOSE OF THE BODY IDENTIFIED AB VE
0 ,-Signature of rlrrk m deputy ITY OR TOWN DATE
13 Joseph P. Barnhart, deputy, 14. rutland city. 15. 10/25/87
A
CEMETERY OR CREMATORY AUTHORITIES SHALL FILL OUT SECTIONS BELOW.
BODY WAS DATE NAME OF CEMETERY OR CREMATORY SECTION LOT NO.
/ <j i 1
's
17! -'r 18. ,.
L.- _c,-r ! 19. 20.
❑ BURIED
LOCATION (CITY OR TOWN) (STATE) SIGNATURE OF SEXTON OR
CREMATED OTHER PERSON IN CHARGE
❑ STORED Y 1.,-ti
I 1•, //�,. .,_
16. 21. 22.