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VDH-PHS-BTP-2011 VENNONT DEPARTMENT OF HEALTH Permit No. 37$
.BURAA �:. RANSIT PERMIT
Permit f•' :: al, Disinterment and Reinterment
1. Decedent's Name 2. Sex 3. Date of Death
MURIEL FRANCES BELDEN Female April 13, 2018
111 4. City/Town of Death 5. Date of Birth 6. Place of Birth
Burlington, VT Aug. 12, 1942 Kingston, New York
7. Name and Address of Funeral Director PO Box 543
Wilcox & Regan Funeral Home/11 Algonkin St . , Ticonderoga, NY, 12883
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)
III 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 187V.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 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
Signature of Sexton/Cemetery Official Date
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
0 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(Tjtle 18,V.S.A. 5201)
Signature of Clerk/Deputy or Funeral Director City/Town Date
AliiiIP 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 Crematory Queensbury, NY Apr. 16, 2018
PERT ISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A.5201)
Sig ture of Clerk/D uty or Funeral Director City/Town Date
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Thispermit i to sled with the City/Town Clerk by the 10m day of the month following disposition.(Title 18 V.S.A.5215)
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