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Sapienza, Anthony VDM.PHS•BTP-2011 VERMONT DErARTMENT OF HEALTH Permit No. 2�L _ BURiAL•TRANSIT PERMIT Permit for Removal, Disinterment and Reinterment 1.Decedent's Name 2. Sex 1 Date o(Death Anthony Santo Sapienza Male October 16,2017 4.City/Town of Death 5. Date of Birth 6. Place of Birth Burlington May 19, 1970 Albany,NY T. Name and Address of Funeral Director Wicox&Regan Funeral.Horne, 11 Algonkin St.,F.O. Box 543,Ticonderoga,NY 12883 PERMISSION REQUESTED FOR: (Check only ono bbx and complete the appropriate section) Temporary Storage or Donation(Section Ay Q Cremation(Section C) ❑Burial or Entombment(Sectr)n D) © Removal From Temporary Storage/PI*.e of DonationorDisinterment(Section B) rid Removal From State(Section E) SE(:1IUN A IF TEMPORARY tiTORAf;F (` risy.:ATION IN t•=RR,1ONT 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 ICityTrown Date 'Signature of Sexton/Cemetery Offic+ai or Representative of Organization Receiving Donation Date t'SL•C:TION 13a Ir REmOVAl:FROM TcMPORARY TORAGJJPLAci: e OONATiON:O(R MINT eT Name of Cemetery/Place or Facility from which body is being removed City/Town Date PERMISSION GIVEN TO DISPOSE or SAiD BODY AS STATED ABOVE(Title 1a,V.S.A.5201) Signature of Clerk/Deputy or Funeral Director City/Town Date '.nature of Sexto Cerrete Official Date • SECTION C IF CREMATION IN VERIIIIO t 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 Crematoriu Official Container Number Date ~� SECTION D:1r BURIAL OR ENTOMBMENT iN VERMONT Name of Cemetery City/Town Date 1 I PERMISSION GIVEN TO DISPOSE OF SAID BODY AS.STATED At3OVE(Title 18,V.S.A.5201) Signature of Clerk/Deputy or Funeral Director City/Town Date Body was: ❑ Buried El Entombed Date Section Lot Number Grave Number Signature of Sexton/Cemetery Official SECTION E. it RtMOVALFRiOM STATE Name of Cemetery or Place to where body is being taken City/Town,State or Country Date Pine View Crematory Queensbury,NY March 27, 2018 PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A.$201) Si. •tune of Clerk/De y or Funeral Director Cit /Town Date { / JIB i ._ — 27- This permit is to filed with the City/Towi Clerk by the 10th day of the m th following deposition.(Title 18 V.SA.5215i