Carpenter, Logan James VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. -7
BURIAL-TRANSIT PERMIT Permit for Removal, Disinterment and Reinterment -1/
y
1. Decedent's Name 2. Sex 3. Date of Death
Logan James Carpenter Male October 28,2019
4. City/Town of Death 5. Date of Birth 6. Place of Birth
"",Burlington February 14, 1989 Glens Falls,NY
7. Name and Address of Funeral Director
Jeffrey C. Chalmers, M.B. Kilmer Funeral Home, 136 Main Street South Glens Falls,NY 12803
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) ® 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 City/Town Date
Signature of Sexton/Cemetery Official or Representative of Organization Receiving Donation Date
SECTION B: IF REMOVAL FROM TEMPORARY STORAGEIPLACE 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
Signature of Sexton/Cemetery Official Date
SECTION • VERMONT
Name of Crematorium CityMown 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
SECTIONBURIAL 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 • FROM STATE
Name of Cemetery or Place to where body is being taken City/Town, State or Country Date
Pine View Crematory Queensbury,NY October 30, 2019
PERMISSION GIVEN TO ID BODY AS STATED ABOVE(Title 18,V.S.A. 5201)
Signature of Clerk/D puty o uneral irector City/Town Date p
Th' r it to filed with the City/Town Clerk by the 10th day of the moni following disposition.(Title 18 V.S.A.5215)
STATE OF VERMONT-AGENCY OF HUMAN SERVICES-DEPARTMENT OF HEALTH
OFFICE OF THE CHIEF MEDICAL EXAMINER
4 MEDICAL EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
PERMIT NO. 2019c - 3606
Full name of decedent: Logan James Carpenter
Decedent's address:
17 Thomas Ave
Moreau,NY
Date of death: October 28, 2019 Town of death: Burlington
Cause of death certified by: Elizabeth A. Bundock
Permission to cremate the body of this decedent at:
Pine View Crematory
Queensbury,NY
Has been requested by: Jeffrey C. Chalmers
Vermont Funeral Director License Number: 022-0001172
Being sufficiently informed as to the causes and circumstances of the death of the above described
decedent, permission is hereby granted to cremate the body as requested per 18 V.S.A. Section 5201.
Date: October 29, 2019
Signed: (Via the Vermont Electronic Death Registration System)
Steven L. Shapiro, MD
Chief Medical Examiner
Office of the Chief Medical Examiner
111 Colchester Ave., Baird 1
Burlington, VT 05401
VDH-OCME-CP-01/201 1