Richards, William 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
William Martin Richards Male May 15,2011
4. City/Town of Death 5. Date of Birth 6. Place of Birth
Rutland City September 24, 1938 Randolph,VT
1111 7 Name and Address of Funeral Director
Durfee Funeral Home, PO Box 86, 119 North Main Street,Fair Haven,VT 05743
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)
VIXIIii.i v Ia1:MPORARY STORAGE OR DONATION IN VERMONT
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 City/Town Date
Signature of Sexton/Cemetery Official or Representative of Organization Receiving Donation Date
SECTION B: IF R MOVAL 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
I'IX911.1 r' ■Ia•REMATION 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
• SECTION D: IF ::URIAL 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 ❑ Entombed Date
Section Lot Number Grave Number Signature of Sexton/Cemetery Official
1111
SECTION E: IF 'EMOVAL FROM STATE
Name of Cemetery or Place to where body is being taken City/Town, State or Country Date
Pine View Crematory Queensbury,NY May 17, 2011
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A. 5201)
Si nature of Clerk/ eputypr Fu ro Cityraown !Date
This perm t is to be filed with the City/Town Clerk by the 10th day of the month following disposition.(Title 18`V.S.A.5215)