Blood, Richard VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. 10
BURIAL-TRANSIT PERMIT
Permit oval, Disinterment and Reinterment
1. Decedents Name 2. Sex 3. Date of Death
Richard John Blood Male February 08,2015
4. City/Town of Death 5. Date of Birth 6. Place of Birth
Burlington August 11, 1938 Ticonderoga,NY
1111 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) EZ 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 I 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
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 1Date
Body was: 0 Buried ❑ Entombed Date
Section Lot Number Grave Number Signature of Sexton/Cemetery Official
11111 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 February 10, 2015
PERMI ION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A. 5201)
Sign a of Cler Deput r unekl Director City/Town
/,`/ 1G� t,cA16 ✓ 1 Date
2 -//. d
This permit is to be filed with the City/Town Clerk by the 10th day of the month following disposition.(Title 18 V.S.A.5215)