Jones, Marilyn VDH-PHS-BTP-2011 VERMINIT DEPARTMENT OF HEALTH Permit No. if 3 S
BURIAL-TRANSIT PERMIT
Permit for Removal:Disinterment and Reintennent
1.Decedents Name 2.Sex T Dale of Death
Marilyn B.Jones Female lunge 08,2016
4,City/Town of Death 5.Date of Bit* 6.Place of Birth
Rutland City June 17, 1942, Cleveland,OH
7.Name and Address of Funeral Director
Jilison 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) 0 Cremation(Section C) 0 Burial or Entombment(Section D)
0 Removal From Temporary Storage/Place of Donation or Disinlermenl(Section B) Removal From State(Section E)
SECTION A IF TEMPORARY 3 T ORAL[ OP DONATION IN VEFaMONT
Name of Cemetary/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 ICityfrown Date
Signature of Sexton/Cemetery Official or Representative of Organization Receiving Donation Date
SECTION B IF REMOVAL FROM TEMPORAF,v STORAGE a_ACE C'C CONA-ION OR DISIN-ERUENT
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/Toan Date
Signature of Seaton/Cemetery Oraicial 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 CIerWDeputy or Funeral Director City/Town Date
Signature of Crematorium Official Container Number Date
SECTION D IF BURIAL OF ENTOMBMENT IN VERMONT
Name of Cemetery City/Town Date
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Tide 18.V.S.A.5201
Signature of Clertc/Deputy or Funeral Director City/Towm Data
Body was'. 0 Buried 0 Entombed Dade
Section lot Number Grave Number Signature of Sexton/Cemetery Official
Name of Cemetery or Place to where body is being taken City/Town,State or Country Date
Pine View Crematorium Queensbury,NY 'Mg June 09,2016
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE itle 18,V.S.A.5201)
S of♦. • . , F C1JIaDL
Date
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This permit is -11 .with the City/room Clerk by the 10th day of the month fottowin disposition.(Tide 18 V.SA 5215)