Stefanic, Edda-Louise L
VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF1HEALTH
BURIAL-TRANSIT PERMIT Permit No. C73
. Permit for Removal, Disinterment:and Reinterment
1. Decedent's Name ""� 2. Sex 3. Date of Death
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0�� 4. City/Town of Death 5. Date of Birth 6. Place of Birth
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7. Name and Address of Funeral Director
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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) emoval From State(Section E)
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERMONT
0 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 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
1 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
III
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
IIII Body was: ❑ Buried ❑ Entombed Date
Section Lot Number Grave Number Signature of Sexton/Cemetery Official
SECTION E: IF REMOVAL FROM STATE
Nram-
e of Ce etery or Place to where body is being taken City/Town,State or Country Date
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PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,VtS.A.5201)
Sign/re of Clerk/Deputy r Funeral Director C
ity/Town Date
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permit is o fi ed with the City/Town Clerk by the 10t1 day of the month following disposition.(Title 18 V.S.A.5215)