Rafferty, William t 1
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
WILLIAM M. RAFFERTY MALE Nov. 18, 2015
4. City/Town of Death 5. Date of Birth 6_Place of Birth
Burlington, VT June 26, 1933 . Ticonderoga, NY
`_
7. Name and Address of Funeral Direr 1 1 Algonkin St.
cto
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) 0 Cremation(Section C) ❑ Burial or Entombment (Section D)
❑ Removal From Temporary Storage/Place of Donation or Disinterment (Section B) TRemoval From State(Section E)
SECTION A:IF TEMPORARY STORAGE OR DONATION IN VERMONT
Name of Cemetery/Place or Donation Facility 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 or Representative of Organization Receiving Donation Date
SECTION B:IF REMOVAL FROM TEMPORARY STORAGE/PLACE OF DONATION OR DISINTERMENT
Name of Cemetery/Place or Facilityfrom 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
'i
SECTION C: IF CREMATION IN VERMONT
Name of Crematorium City/Town Date
/r
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
Name of Cemetery City/'Town Date
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE (Title 18, V.S.A. 5201) i
Signature of Clerk/Deputy or Funeral Director City/Town Date
Body was: 0 Buried 0 Entombed Date •
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 Oueensbury, NY 11 -20-2015
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A. 5201)
Sig Y;A/,/. —'&iffif"''''
re of Clerk/Depu o Funeral Director ( City/Town Date
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