LaChapelle, Catherine O
DH-PHS-BTP-89a VERMONT DEPARTMENT OF HEALTH
BURIAL-TRANSIT PERMIT Permit No.3
Permit for Removal, Disinterment and Reinterment
1.Decedent's Name(first, middle, last) 2. Sex 3. Date of Death
• Catherine A. LaChape le Female April 13, 2017
4.City/Town of Death 5. Date of Birth 6. Place of Birth
City of Rutland Mar.23, 1936 Benson Vermont
7. Name and Address of Funeral Director or Authorized Person
Jay Jillson Jillson Funeral Home 46 Williams St Whitehall NY 12887
PERMISSION REQUESTED FOR:(Check only one box and complete appropriate section)
❑Temporary ❑Removal from E Cremation ❑Burial or
Storage Temp. Storage or (Section C) Entombment
(Section A) Disinterment (Section D)
• (Section B)
SECTION A (If temporary storage complete this section.)
Place of Storage(Name of Cemetery or Vault) City/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION B. (If removal from temporary storage or disinterment complete this section )
Name of Cemetery or Vault from which body is being removed City/Town Date
Name of Cemetery where body is being taken City/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION C. (Complete this section if body will be cremated.)
Name of Crematorium City/Town, State D to
Pine View Crematory Town of Queensbury 4/19/2017
P e k ISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A. 5201)
• ignat re of Clerk o Q.uty City/Town Dat
\. , r �- �Vdl City of Rutland 4/19/2017
- • t rem. olm Official Container Number Date
.('f g: 3/ 5-- ryi7
SECTION D: (Complete this section if body cremains will be buried or entombed )
Name of Cemetery City/Town Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
IIISignature of Clerk or Deputy City/Town Date
Body/Cremains were ❑Buried ❑ Entombed Date
Name of Cemetery Section Lot Number Grave Number
City/Town, State Signature of Sexton/Cemetery Official
This 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)