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VDH-PHS-8TP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. 7Z 2-
BURIAL-TRANSIT PERMIT
Permit for Removal,Disinterment and Reintemient
1.Decedent's Name '2. Sex 3.Date of Death
Dorothy L.Scott Female September 29,2016
4,City/Town of Death 5.Date of Birth 6. Place of Birth
Rutland City September 17, 1925 Troy,NY
7.Name and Address of Funeral Director
Jillson Funeral Home,Inc.,46 Williams Street,Whitehall,NY 12887
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 Slorage/Place of Donation or Disinterment(Section B) 0 Removal From State(Section E)
SECTION A: IF TEMPORARY STORAGE 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 'City/Town Date
Signature of Sexton/Cemetery Official or Representative of Organization Receiving Donation Date
SECTION B IF REMOVAL FROM TEVPORARY =..TORAGE:PLACE 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(Tile 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 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
Body was: ❑ Buried ❑ Entombed Date
Section Lot Number Grave Number 'Signature of Sexton/Cemetery Official
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Name of Cemetery or Piece to where body is being taken City/Town.State or Country Date
Pine View Crematorium Queensbury,NY October 04,2016
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE iTitle 18,Y.S.A.5201)
Signetkra of CI Fur»a�IR� R.L�
City/Towri -Otte
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This permit is t e led with the City/Town Clerk by the 10th day of the month following.ixposition.(The 18 V.S.A 5215)