Bessler, Paul VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No.
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name 2. Sex 3. Date of Death
Paul Douglas Bessler Male December 23, 2016
4. City/Town of Death 5. Date of Birth 6. Place of Birth
Middlebury April 18, 1974 Garden Grove, CA
III 7. Name and Address of Funeral Director
Wilcox&Regan Funeral Home, 11 Algonkin St., 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)
0 Removal From Temporary Storage/Place of Donation or Disinterment(Section B) 611 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 ICity/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
ID 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: ❑ Buried 0 Entombed Date
0 Section Lot Number Grave Number Signature of Sexton/Cemetery Official
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 2iQi,ediec[LD Queensbury,NY / 2009 December 28, 2016
PER ISSION GIVEN TO DISPO _-SAl BODY AS STATED ABOVE(Title 18, V.S.A. 5201)
Si ure of Cler ty or neral Director 2 City/Town Date
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This permit,�is to be filed with the City/Town Clerk by the 10th day of the month following position.(Title 18 V.S.A.521 )
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