Smith, Christina _ ,t
VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. 2-
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name 2.Sex 3. Date of Death
Christina Smith Female December 30,2011
4.City/Town of Death 5. Date of Birth 6. Place of Birth
• Colchester January 19, 1923 Obertsausen,Germany
7. Name and Address of Funeral Director
Densmore Funeral Home, 7 Sherman Ave.,Corinth,NY 12822
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) ®Removal From State(Section E)
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERMONT
el 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 1Cityfrown 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 I 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(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 I Date
Body was: ❑ Buried 0 Entombed Date
1110 Section Lot Number Grave Number Signature of Sexton/Cemetery Official
SECTION E: IF REMOVAL FROM STATE
Name of Cemetery or Pla to where y is being taken City/Town,State or Country Date
Pineview Crematory i (Co Fhgv eensbury,NY January 02,2012
PE SSION GIVEN TO DISPOSE OF SAID BODY AS IiTATED ABOVE(Title 18,V.S.A. 5201)
• n re of Cle pu r Funeral Director Crown I Date
A, COLc'y-{i 72 1)6C, 3/,..20 l(
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)