Russell, Gerald s
VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. IL
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedents Name 2.Sex 3.Date of Death
Gerald Benway Russell Male December 31, 2014
4. City/Town of Death 5. Date of Birth 6. Place of Birth
Rutland City April 05, 1934 Ticonderoga,NY
7. Name and Address of Funeral Director
Wilcox&Regan Funeral Home, 11 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) ❑Burial or Entombment(Section D)
❑ Removal From Temporary Storage/Place of Donation or Disinterment(Section B) Q 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 STATED ABOVE (Title 18,V.S.A.5201)
Signature of Clerk/Deputy or Funeral Director ICity/Town Date
Signature of Sexton/Cemetery Official or Representative of Organization Receiving Donation Date
SECTION B. IF REMOVAL FROM TEMPORARY STORAGE/PLACE CF 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 1Cityfrown 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
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: 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 Queensbury,NY January 02,2015
PER ON GIVEN TO DISPOSE OF SAI s B 1AS STATED ABOVE le 18,V.S.A.5201)
Sig tur of Clerk/D al D. ;. r 1Date
/ --726°A.5
This permit Is be • a ity/Tow Clerk by the 10 day of a month following disposition.(Title 18 V.S.A.5215)