Charboneau, Katherine 1,
4
VDH-PHS-BTP-201 1 VERMONT DEPARTMENT OF HEALTH Permit No. 150
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name 2. Sex 3. Date of Death
KATHERINE JEAN CHARBONEAU FEMALE FEB. 25, 2015
4. City/Town of Death _ 5. Date of Birth 6. Place of Birth
4114 BURLINGTON, VT OCT. 18, 1930 TICONDEROGA, NEW YORK
7. Name and Address of Funeral Director 1 1 Algonkin st.
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) ❑ Cremation(Section C) ❑ Burial or Entombment (Section D)
❑ Removal From Temporary Storage/Place of Donation or Disinterment (Section B) NEf Removal From State(Section E)
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERMONT
0 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 STR.;AGE/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 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)
J-' Signature of Clerk/Deputy or Funeral Director City/Town Date
Signature of Crematorium Official Container Number Date
.46 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
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Body was: ❑ Buried . ❑ 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 QUEENSBURY, NY . FEB. 26, 2015
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A. 5201)
Sig - re of Clerk/ ut r/Fuunneeral Director City/Town Date
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/ `his permit is to be filed with the City/Town Clerk by the 10th of the month following disjposition.(Title 18 V.S.A.5215)