Hotte Jr., Gary i, ‘
VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. Sen
BURIAL-TRANSIT PERMIT
Permit for Removal,Disinterment and Reinterment
1. Decedent's Name 2. Sex 3. Date of Death
GARY WILLIAM HOTTE_ JR Male June 17, 2017
4. City/Town of Death 5. Date of Birth 6. Place of Birth
1111/ Burlington, VT Nov. 8, 1981 Burlington, VT
7. Name and Address of Funeral Director 12883
Wilcox & Regan Fueeral Home, 11 Algonkin St. . POBox 543. Ticonderoga, NY
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) Vilemoval From State(Section E)
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERMONT
elName 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
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
Signature of Crematorium Official Container Number Date .
.4110
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
1111 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 June 22, 2017
PE' ISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A.5201)
Sit - ure of C rk/Deputy or Funeral Director City/Town Date
This p it is to be filed with the City/Town Clerk by the 10 day of the month following disposition.(Title 18 V.S.A.5215)