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VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. 54
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name 2. Sex 3. Date of Death!�
Robert Hoffman Leander Male August 20, 2016
4.City/Town of Death 5. Date of Birth 6. Place of Birth
Burlington March 29, 1947 Holden, MA
7. Name and Address of Funeral Director
410 Wilcox&Regan Funeral Home, 11 Algonkin St., Ticonderoga,NY 12883
PERMISSION REQUESTED FOR: (Check only one box and complete the appropriate section)
❑Temporary Storage or Donation(Section A) 0 Cremation(Section C) 0 Bu-ial or E tombment(Sec.ior D)
0 Removal From Temporary Storage/Place of Donation or Disinterment(Section B) [Q Removal From State(Section E)
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERMONT
Name of Cemetery/Place or Donation Facility City/Town Date
III 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 ICity/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(Title 18,V.S.A.5201)
Signature of Clerk/Deputy or Funeral Director City/Town Date
Signature of Crematorium Official Container Number Date
Sc •. i• :1- •- 1 • , : t 1 Iv - r •.
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 I Date
Body was: 0 Buried 0 Entombed DateIII i
Section Lot Number Grave Number Signature of Sexton/Cemetery Official
SECTION E: IF REMOVAL FROM STATE
Name of Cemetery or Place to where body is being taken City/Town, State or Country Date
Pine View Crematory Queensbury,NY 1 7.1,0LI August 21, 2016
PER SION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A. 5201)
Sig - re of Clerk/Dep o uneral Director Cippwn Date
his 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)