Brown, Jr. Robert 4
VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. LI S
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name 2. Sex 3. Date of Death
Robert Charles Brown, Jr. Male January 26, 2011
4. City/Town of Death 5. Date of Birth 6. Place of Birth
Castleton September 05, 1946 Rutland City, 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) ❑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 VERIVIONT
Name of Cemetery/Place or Donation Facility City/Town Date
0 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 I City/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
410 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 0 Entombed Date
Section Lot Number Grave Number Signature of Sexton/Cemetery Official
al
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 January 27, 2011
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A. 5201)
Sign re of Clerk/Deputy or Funeral Director City/T wn Date
�. � - _ G u �� l/ T. fri.aG/ 2O//
This is to be filed with the Ci /Town Cle4Cb the 10th of the month dis osition. 8 V.S.A.5215)
permitCity/Town Y day following p