Herrman, Martha 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
Martha A. Herrman Female December 29, 1998
4. City/Town of Death 5. Date of Birth 6. Place of Birth
Middlebury, VT Jan. 31 , 1904 Brooklyn, NY
7. Name and Address of Funeral Director or Authorized Person
Alexander Funeral Home Warrensburg, New York 12885
PERMISSION REQUESTED FOR: (Check only one box and complete appropriate section)
❑Temporary ❑Removal from E Cremation ❑Burial or
Storage Temp. Storage or (Section C) Entombment
4110 (Section A) Disinterment (Section D)
(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.')
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 Viwe Crematory Queensbury, New York Jan.4, 1999
PER SSION IS EN To.DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
Si re •• er r De,1111
Cit /Towndl Date
Myidebury, VT Dec. 29, 1998
u o rematori dal Container Number+e ya?7(
SECTION D: (Complete this section if body/cremains will be buried or entombed.)
Name of Cemetery City/Town Date
0 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)