Nourse, Jr. Harold S.
1
VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. 7 tie)
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Renterment
1. Decedent's Name 2. Sex 3. Date of Death
Harold Gardner Nourse,Jr. Male May 06, 2011
4. City/Town of Death '5. Date of. firth 6. Place of Birth
Rutland City March 27, 1929 Burlington, VT
• 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) 0 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
Name of Cemetery/Place or Donation Facility City/Town Date
IIIPERMISSION 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 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
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
ill 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: 0 Buried ❑ Entombed Date
Section Lot Number Grave Number Signature of Sexton/Cemetery Official
1111
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 May 09, 2011
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A. 5201)
Si ature of Clerk/Deputy or Funeral Director City/T wn Date
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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)