Marcy, Henry 1 . ik
VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. Co Y/
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedents Name 2. Sex 3. Date of Death
Henry E. Marcy Male December 27, 2011
4. City/Town of Death 5. Date of Birth 6. Place of Birth
0 Burlington October 05, 1927 Poultney, VT
7. Name and Address of Funeral Director
Jillson Funeral Home,Inc.,46 Williams Street, Whitehall,NY 12887
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) Fij Removal From State(Section E)
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERMONT
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 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
0 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 1Date
Body was: 0 Buried 0 Entombed Date
IDSection Lot Number Grave Number Signature of Sexton/Cemetery Official
SECTION E: IF REMOVAL FROM STATE
Name of Cemetery or Place to a bod is being taken City/Town, State or Country Date
L
Pine View Crematorium CQ �� ueensbury,NY December 30, 2011
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A.5201)
Sig ature of Clerk/D uty or uneral irector City/Town Date
t 4A� 50A0rr Win, (ierfm4 f�ot a , ao lf
This permit)is o be filed with the City/Town Clerk by the 10th day of the ponth following disposition.(Title 18 V.S.A.5215)