Tilley, Bettina DH-PHS-BTP-8 VERMONT DEPARTMENT OF HEALTH -t-
BURIAL-TRANSIT PERMIT Permit No.
Permit for Removal, Disinterment and Reinterment
1. ecedent's Name(first, middl , last) , 2,5ex 3. Date of Death
• 4.City/Town of Death 5. Date of Birth 6. Place of Birth
Fi¢/,/ / /71)e,q) , r- f'..z/. 7, / /9 f//y.,PT/=c,/c'v ; e 7;
7. me and Address of Funeral Director or Authorized Person _ _
C6.6€4l - 0 Leif - /--Alerr.-e, //j AA /ifete r.,,5i� AreL-c'(- / 77 r t/7-
RMISSION REQUESTED FOR:(Check only one box and complete appropriate section)
❑Temporary ❑Removal from Cremation E Burial or
Storage Temp. Storage or (Section C) Entombment
(Section A) Disinterment (Section D)
0 (Section B)
SECTION A: (If temporary storage complete this section,)
Place of Storage(Name of Cemetery or Vault) City/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION B (If removal from temporary storage or disinterment. complete this section.I
Name of Cemetery or Vault from which body is being removed City/Town Date
Name of Cemetery where body is being taken City/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION C: (Complete this section if body will be cremated.)
Nape of Crematorium City/Town, State A. 9, ,993
te
NapiUe- J/e be.) e,P eM )77-a/a A q v.e e xi�'/,�r�n?, ,u�7
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
S iture of Clerk or D puty City/Tow ate
.� - t!y G � i , (n . ►- Fi isle re of Cr atorium Offi ' I Container Number Date
x
SECTION D: (Complete this section if body cremains will be buried or entombed.)
Name of Cemetery City/Town Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
• Signature of Clerk or Deputy City/Town Date
Body/Cremains were ❑Buried ❑Entombed Date
Name of Cemetery Section Lot Number Grave Number
City/Town, State Signature of Sexton/Cemetery Official
This permit is to be filed with the City/Town Clerk by the 10th day of the month following disposition. (Title 18,V.S.A. 5215)