Carr, Evelyn DH-PHS-58-78
STATE OF VERMONT
BURIAL-TRANSIT PERMIT Permit No
11110 DECEASED—NAME FIRST MIDDLE LAST SEX DATE OF DEATH/Month,Day,Yea 1
1 Evelyn L/ Carr 2Fesiale 3 3/24/88
RACE—(White,Black, AGE LAST BIRTH UNDER 1 YEAR UNDER 1 DAY DATE OF BIRTH COUNTY OF DEATH
American Indian, till ite DAYi4ear5t 72 MOS. DAYS HOURS MIN. (Month.Uay }bar) Rutland
4 ETC.ISpertfy/ 5A SB 5C 6 1/14/l6 7A
CITY,TOWN OF DEATH zoo Street and h'um he.l East St• 7D Inpat. ❑ ER ❑ C
r
PERMISSION REQUESTED FOR.
tli BURIAL kiC CREMATION ❑ TEMPORARY STORAGE
!complete/tern/2 below/
8
PLACE OF DISPOSITION!Cemetery or Crematory/ (CITY OR TOWN) (STATE)
9 Pine Crematorium Queensbury, NY.
NAME OF FUNERAL DIRECTOR BUSINESS ADDRESS
O 10 Aldous Funeral Home 11 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.
v
O PERMISSION IS6�E��-8 GRANTED TO REMOVE AND DISPOSE OF THE BODY IDENTIFIED ABOVE
Srgnature o/clerk r deput CITY OR TOWN DATE
townof
13 � /1 Jn e h P. Rarnhart . P , 14.Wallingford, 15. 3/24/88RY OR CREMATORY AUTHORITIES SHALL FILL OUT SECTIONS BELOW.
7r -P.2/
BODY WAS DATE NAME OF CEMET,ERR.Y/ORR CR/EMMAAT/OR/Y //1 ,Arn' ././�/ SECTION LOT NO.
BURIED17
18.P/'4//�- !/ //" NJ V/r��/'/d<�/rio.r19. 20ill .
LOCATION (CITY OR TOWN) (STATE) SIGNATURE OF SEXTON OR
CREMATED OTHER PERSON IN CHARGE
❑ STORED �/ /�'//� i'I
16. 21&aje0"I YS3 / , / / 1 - 22.