Chamberlain, Patricia VDH-PHS-BTP-2011 VERMON1i DEPARTMENT OF HEALTH Permit No.
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name Sex Date of Death
Patricia Ann Chamberlain 12.
Female 13.
March 19, 2015
4. City/Town of Death 5. Date of Birth 6. Place of Birth
Burlington (January 13, 1948 'Ticonderoga,NY
0 7. Name and Address of Funeral Director
Wilcox& Regan Funeral Home, P.O. Box 543 Algonkin St., 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)
❑ Removal From Temporary Storage/Place of Donation or Disinterment(Section B) Et Removal 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 S STATED ABOVE(Title 18, V.S,A,5201) -
Signature of Clerk/Deputy or Funeral Director0
I 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
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 I Date
Body was: ❑ Buried 0 Entombed Date
Section Lot Number Grave Number Signature of Sexton/Cemetery Official
1111 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 March 21, 2015
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A. 5201)
ature of r eputy or Funeral Director Cityyy��/Town Date
r' /.��ie6-(A-6-7Z2 Y -2(-2-al
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)