Grady, Patricia VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No.
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name 2.Sex 3. Date of Death
Patricia R Grady Female April 22,2018
4. City/Town of Death 5. Date of Birth 6. Place of Birth
4110 Burlington March 17, 1929 Chicago,IL
7. Name and Address of Funeral Director
Singleton Sullivan Potter Funeral Home, 407 Bay Rd, Queensbury,NY 12804
PERMISSION REQUESTED FOR: (Check only one box and complete the appropriate section)
❑Temporary Storage or Donation(Section A) ❑Cremation(Section C) ❑Burial or Entombment(Section D)
❑ Removal From Temporary Storage/Place of Donation or Disinterment(Section B) Et Removal From State(Section E)
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERMONT
Name of Cemetery/Place or Donation Facility City/Town Date
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A.5201)
Signature of Clerk/Deputy or Funeral Director ICity/Town Date
Signature of Sexton/Cemetery Official or Representative of Organization Receiving Donation Date
SECTION B: IF REMOVAL FROM TEMPORARY STORAGE/PLACE OF DONATION OR DISINTERMENT
Name of Cemetery/Place or Facility from which body is being removed City/Town Date
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A.5201)
Signature of Clerk/Deputy or Funeral Director 'City/Town Date
Sig,-ture of Sexton/Cemetery Official , \� Date
. , /p - ifrit r r akkei'
27 2oIP
SECTION C: IF CREMATION IN VERMONT
Name of Crematorium City/Town Date
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A. 5201)
Signature of Clerk/Deputy or Funeral Director City/Town Date
Signature of Crematorium Official Container Number Date
SECTION D: IF BURIAL OR ENTOMBMENT IN VERMONT
Name of Cemetery City/Town Date
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A.5201)
Signature of Clerk/Deputy or Funeral Director City/Town (Date
Body was: ❑ Buried ❑ Entombed Date
Section Lot Number Grave Number Signature of Sexton/Cemetery Official
SECTION E: IF REMOVAL FROM STATE
Name of Cemetery or Place to where body is being taken City/Town, State or Country Date
Pine View Cemetery Queensbury,NY April 27,2018
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A.5201)
Signat of Clerk/De uty or F ne-al Director City/Town Date
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)