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VDN-PHS-BTP 2011 VERMONT DEPARTMENT OF HEALTH Permit No._ 1
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BURIAL-TRANSIT PERMIT
Permit for Removal,Disinterment and Reinterment
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1.Decedentts Name - ir x . ate ear
Dotick Pelerin,Jr, Male rJune 18, 2016 —_.__..
a. City/Town of Death 5. Date of Birth 8.Place of Birth
IJeffersonville March 10, 1930 Crown Point,VT
`7.Name and Address of Funeral Director
Wilcox& Regan Funeral Home, 11 Algonkin Street,Ticonderoga,NY 12883
PERMISSION REQUESTED FOR; (Check only one box and complete the appropriate section)
0 Temporary Storage or Donation(Section A) Q Cremation(Section 0) 0 Burial or Entombment(Section D)
0 Removal From Temxiorary Storage/Piece of Donations or Disinterment(Section B) ®Removal From State(Section E)
`i '(..hIUN A If TTMp(:*:ARY `iT,JkAGF r)S� JONATICN 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 TDatte
Signature of SextoniCemetery Official or Representative of Organization Receiving Donation Date
i
SEC.TIQN El F l[.MO\.AL FROM TEMPORARY ST7,f A' [ PLA(.:E. OF DO NA-RUN CAR GiSiNTERMEPT
Name of Cerrmetery/Place or Fae mRy from which body is being removed City/Town Date
'PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE Citle 18,V.SA.5201)
Signature of Clerk/Deputy or Funeral Director City/Town Date
'Signature of Sexton/Cemetery Official Date
SFCTION C IF CREMATION IN VFRMONl'
Name of Crematorium i City/Town Date
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(title 18,V.S.A.5201)
Signature of Cleric/Deputy or Funeral Director City/Town Date
Signature of Crematorium Official Container Number Date
SEf.TION O IF ruRIA;L OR ENICMBMENT IN VEI?MON?
Name of Cemetery City/Town Date
rPERMISSION 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 0 Entombed Date
Section [Lot Number Grave Number Signature of Sexton/Cemetery Official
St';TION L- IF REMO^/AL FROM STATE
Name of Cemetery or Place to where body is being taken City/Town,Slate or Country Date
Pine View Crematory IQueensbury.NY June 24,2016
PERMISSION GIVEN TO DISPOSE"OF SAID BO Y AS STATED ABOVE Title 18,V.S.A. 5201)
Signature Cl a or F al f City/Town i Date
.is it is to be fled with the City/Town Clerk by the 18fh day of the month fallowing disp sISan.(Title 18 V.S.A.5218)