Davis, Thoedore r
DH-PHS-BTP-89a VERMONT )EPARTMENT OF HEALTH
BURIAL-TRANSIT PERMIT Permit No. I C L
Permit for Removal, Disinterment and Reinterment
•
1. Decedent's Name(first, middle, last) 2. Sex 3. Date of Death
Theodore Ellsworth Davis Male February 27,2011
4.City/Town of Death 5. Date of Birth 6. Place of Birth
Rutland, Vermont June 23, 1927 Pittsfield, Vermont
7. Name and Address of Funeral Director or Authorized Person
James C. Aubin: Durfee Funeral Home, 119 No. Main Street,Fair Haven,VT 05743
PERMISSION REQUESTED FOR:(Check only one box and complete appropriate section)
❑Temporary ❑Removal from XX( emation E Burial or
0 Storage Temp. Storage or (Section C) Entombment
(Section A) Disinterment
(Section B) (Section D)
SECTION A: (If temporary storage, complete this section.)
Place of Storage(Name of Cemetery or Vault) City/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A.5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION B. (If removal from temporary storage or disinterment. complete this section.)
Name of Cemetery or Vault from which body is being removed City/Town Date
Name of Cemetery where body is being taken City/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION C: (Complete this section if body will be cremated.)
Name of Crematorium City/Town, State Date
Pine View Crematory Queensbury, New York March 1,2011
0 PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
ignature of Clerk or Deputy City/T wn _Date
VSigna Crematori ici Container Number Date
Jai 2 2
SECTION D. (Complete this section if body/cremains will be buried or entombed.)
Name of Cemetery City/Town Date
0 PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Body/Cremains were ❑Buried ❑ Entombed Date
Name of Cemetery Section Lot Number Grave Number
City/Town, State Signature of Sexton/Cemetery Official
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)