Rounds, Bruce r t
VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. 4-1:)
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name 2. Sex 3. Date of Death
Bruce Allyn Rounds Male August 29, 2011
4. City/Town of Death 5. Date of Birth 6. Place of Birth
4111 Rutland City December 02, 1940 Mount Holly,VT
7. Name and Address of Funeral Director
Aldous Funeral Home, 44 North Main Street, Rutland,VT 05701
PERMISSION REQUESTED FOR: (Check only one box.and complete the appropriate section)
❑Temporary Storage or Donation(Section A) iirCremation(Section C) ❑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
ID 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 ICity/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 1City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION C: IF CREMATION IN VERMONT
N me of Crematorium City/Town Date
1 ?Kilo
.4.)y S/34/4 c Ji
PERMISSION GIVEN TO DISPOSE ODSAID BODY AS STATED ABOVE(Title,V.S.A. 5201)
Signature Clerk/Deputy or Funeral Director Ci own Date i
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Signature arCrematonum Official Container Number D to
9
SECTION D: IF BURIAL OR ENTOMBMENT IN VERMONT
III 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 1Date
Body was: ❑ Buried ❑ Entombed Date
alSection 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 August 30,2011
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
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)