Hill, Robert VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. 71).
/ BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1.Decedents Name 2.Sex 3. Date of Death
Robert L. Hill Male October 31,2016
4.City/Town of Death 5.Date of Birth 6. Place of Birth
Burlington April 13, 1940 Crown Point,NY
7.Name and Address of Funeral Director
III Wilcox&Regan Funeral Home, 11 Algonkin St.,P.O. Box 543,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 Burial or Entombment(Section D)
❑ Removal From Temporary Storage/Place of Donation or Disinterment(Section B) 10 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 City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION C:IF CREMATION IN VERMONT
ame 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
• 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 Date
Body was: ❑ Buried 0 Entombed Date
1111 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 November 02, 2016
PERM SSION GIVEN TO DISP BODY AS STATED ABOVE(Title 18,V.S.A.5201)
Sig re of Cie ty r Funeral Direc r City/Town Date
��//VG/ arc/ 1/ r/'26/6
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)