Sidusky, Andrew DH-PHS-BTP-89a VERMONT DEPARTMENT OF HEALTH
BURIAL-TRANSIT PERMIT Permit No.
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name(first, middle, last) 2. Sex 3. Date of Death
Andrew Sidusky male Aug . 13 , 1993
4. City/Town of Death S Ferrisburgh, 5. Date of Birth 6. Place of Birth
Dec .3, 1917 W.Pawlet,Vermont
7. Name and Address of Funeral Director or Authorized Person
Brawn—Mc(1ay Funeral Homes Inc . Bristcl .Vt . 0544'3
PERMISSION REQUESTED FOR:(Check only one box and complete appropriate section)
❑Temporary ❑Removal from C[Cremation ❑Burial or
Storage Temp. Storage or (Section C) Entombment
(Section A) Disinterment (Section D)
(Section B)
SECTION A: (If temporary storage. complete this section.)
lb
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.)
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.)
Name of Crematorium City/Town, State Date
Pine View Crematorium Queensbury, NY. 8/16/93
PERMISS • IS GI • 0 DI POSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
- Sign. .'�f Cler ..-,,-p - City/Town Date
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Ferrisburgh 8/14/93
e •f r atorium Officia Container Number Date
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
S
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)