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VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. 13 9
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1.Decedent's Name 2.Sex 3. Date of Death
Diane L. Stocker Female October 06,2016
4.City/Town of Death 5.Date of Birth 6.Place of Birth
��.. Springfield February 28, 1966 Glens Falls,NY
7_Name and Address of Funeral Director
Jillson Funeral Home, 46 Williams Street, Whitehall,NY 12887
`PERMISSION REQUESTED FOR: (Check orgy one box and complete the appropriate section)
0 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)
SECTION A IF TEMPORARY STCRAGE 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 18,V.S.A.5201)
Signature of Clerk/Deputy or Funeral Director 1City/Town Date
Signature of Sexton/Cemetery Official or Representative of Organization Receiving Donation Date
SECTION B: IF REMOVAL FROM TEMPORARY STORAGE,FLACE OF DC NATION 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.SA.5201)
Signature of Clerk/Deputy or Funeral Director 'City/Town Date
Signature of Sexton/Cemetery Official Date
A f,_, oplp SECTION C: IF CREMATION IN VERMONT
�y- 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 BURIAL OR ENTOMBMENT !N 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 !Dale
Body was: [3 Buried ❑Entombed Date
Section Lot Number Grave Number Signature of Sexton/Cemetery Official
Name of Cemetery or Place to where body is being taken City/Town,State or Country Date
Pine View Crematorium Queensbury,NY October 12,2016
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.SA.5201)
Signature of Cled Funeral Director City/Town Date
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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)