Lindsay, Ronald Y a
VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. ill
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name 2. Sex 3. Date of Death
Ronald J. Lindsay Male Feb. 19, 2015
4. City/Town of Death 5. Date of Birth 6. Place of Birth
1110 Town of Arlington Nov. 16, 1959 Cherry Point NC.
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) ❑ 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 City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION C: IF CREMATIO , _
Name of Crematorium City/Town Date
Pine View Crematorium Queensbury 02/24/2015
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
Whitehall 02/23/2015
Signature of Crematorium Official Container Number Date
1111 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 Date
Body was: ❑ Buried ❑ Entombed Date
III 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
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A. 5201)
Signature of Cle k/ uty or uneral director it own Date _.
( j/� 4,,jf G/�j� if - b, 20j0015
This per s o be filed with the City/Town Clerk by the 10"day of the onth following disposition.(Title 18 V.S.A.5215)