Cook, Stephen t s 1
VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. i(Z
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1.Decedent's Name 2. Sex 3. Date of Death
Stephen Andrew Cook Male January 11, 2016
4.City/Town of Death 5. Date of Birth 6. Place of Birth
Burlington December 17, 1949 Morristown,NJ
410 7.Name and Address of Funeral Director
Wilcox&Regan Funeral Home,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) ❑Cremation(Section C) 0 Burial or Entombment(Section D)
❑ Removal From Temporary Storage/Place of Donation or Disinterment(Section B) Fa 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
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 BURIAL OR ENTOMBMENT IN VERMONT
0 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
Section Lot Number Grave Number Signature of Sexton/Cemetery Official
110 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 14,2016
PER ISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A.5201)
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Si a re of Clerk/D ut Funeral D`ctor City/Town � / Date
This permit is to filed with the City/Town Clerk by the 10th day of the month following disposition.(Title 18 V.S.A.5215)