Leroy, Eugene Jun 1 t 11 1U:4ia Lavigne runerai rm une ,
VDH-PHS-BTP 2011 VERMONT DEPARTMENT OF HEALTH Permit No. 3
BURIAL-TRANSIT PERMIT
Permit for Removal. Disinterment and Reinterment
1.Decedents Name 2.Sex 3.Date of Death
Eugene Leroy Male June 15,2011
4.City/Town of Death 5.Dale of Birth 6. Place of Birth
Burlington August l8, 1934 Kansas City,MO
7.Name and Address of Funeral Director
M.B. Clark,Inc.,Funeral Home,2310 Saranac Ave.,Lake Placid,NY 12946
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 Disiitemient(Section B) Ea Removal From State(Section E)
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERPfON-
Name of Cemetery/Place or Donation Facility City/Town Date
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.SA.5201)
Signature of Clerk/Deputy or Funeral Director City/Town Date
Signature of Sexton/Cemetery Official or Representative of Organization Receiving Donation Date
SECTION 8: I=REMOVAL FROi)I TEMPORARY STORAGE'PLACE OF DONATION OR DISIPITER"JENT
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 I
City/Town .Date
Signature of Sexton/Cemetery Official 'Date
SECTION C: IF CREMATION IN VERMCNT
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 Bt.RI AL OR ENTOP,13}!=NT N VER[u1O> T
'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: 0 Buried CI Entombed Date
Section Lot Number Grave Number Signature of Sexton/Cemetery Official
Mama of Cemetery or Place to wh tr:_hotly Is help®taken City/Town.State or Country Date
M.B.Clark,Inc.Funeral Home Lake Placid,NY June 22,2011
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Tice 18,V.S.A.5201)
Sig of ClerklDeeputy or F al Director City/T wn Date
--s C ` ,�r ter ice 7, 1>
This permit is to be tiled with the City/Town Clerk by the 10th day of the month following chsposition.(Title 18 V.S.A.5215)