Towne, Rhyan VDH PHS STP-2C11 VERMONT DtPAR WENT OF HEALTH Permit No.
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment anc Reinterment
1.Decedent's Name . ex e o a
Rhyan Nicholas Towne Male July 26,2018
4.City/Town of Death 157r:Tate of Birth 6. Place of Birth
Burlington February 18,2010 Glens Falls,NY
7.Name and Address of Funeral Director
Wilcox&Regan, 11 Algonkin.St., Ticonderoga,NY 12883
PERMISSION REQUESTED FOR: (Check only one box and complete the appropriate section)
[l Temporary Storage or Donation(Section A) D Cremation(Section C) ❑Burial or Entombment(Sections D)
Q Removal From Temporary Storage/Place of Donation or Disinterment(Section B) EN Removal From State(Section E)
SECTION A:iF TEMPORARY STORACE OR DONATION IN VERMON I
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
Sf ignature of Sexton/Cemetery Official or Representative of Organization Receiving Donation Date
purettiumouglivitiwokq;.., * -•- - STORAGF/Pt Act OF DONa ION OR DISINTERMENT
Name of Cemetery/Place er .r iiy f,o,m which body is being removed City/Town Date
PERMISSION GIVEN TO t'! i C`t=SAID BODY AS STATED ABOVE(Title 18,V.S.A.5201
Signature of Clerk/Deputy a: , , . <. ''!rector City/Town Date
Signature of Sexton/Cemetery C �..:; Date
SFCTtoN C IF CREMATION IN
Name of Crematorium City/Town Date
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A.5201) i
Signature of Clerk/Deputy or Funeral Director City/Town ]Date
1
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 Es II-REMOVAL hh{ONIS,'JA i e •
Name of Cemetery or Place to where body is being taken City/Town,State or Country Date
Pine View Crematory Queensbury,NY July 30,2018
PERM ION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE1Titte 18 V.S.A 5201,
Signs reotClerk/D unenalDirector City/Towne G� r�-� e�30-De`
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)