Duval, Frances VERMONT DEPARTMENT OF HEALTH Perm No
BURIAL-TRANS1T PERMIT
Perm:tr Removal ()is:Terme-it and Reinte-,ient
Der-elent s Name 2 Sex: 2. Date of Deatn
ranc,:-, \I. )tl\ ii I analc Rik
i 4 ii"itiv Tow- f Death 5 Date of Btiff.! 6 Place of Ertl
ktolILT (I(1. I ti'S I aprart.
Nar-e :171 off:5s ot ; urieral
iincTai 1 ioirc.. "•therman \ L'• orinth, \N I
ESICA REOijAl STED bc:. and corrpiete tee appfo:::,nate sec::on,
-e-T-Pc•af y t',-0-3ge cn'Section Ai El c renatic o 0 Bur a:o ErcThoeIt Secticn
Dist ii;•17 Siacti.2r 0. Rem-cyva c-nDrr. State Sao:
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERMONT
Denat.en I '7,2,41Town Dale
1:-)E IC' DISPOSE OF SAD BOD`f. AS STATED ABOVE ThtIe 18 \v' S A 5201)
C.:.erki/DepLitiv or Funeral recic Tow Dale
or Representative c Organizat or Reoeiving Donation 1 nate
SECTION B: IF REMOVAL FROM TEMPORARY STORAGE/PLACE OF DONATION OR DISINTERMENT
Name ::f Cerretery.filace or Fac!Itty from which body is being removed Crty7iciwn Date
71:: DISPOSE 1W SAC. AS STATED ABOE iThie 18 c S A 52C
SiiLurijf or F, e-a Direiztor Date
Signdturn: of `.-4extan/Cerneter,,. Official Date
SECTION C: IF CREMATION IN VERMONT
N r- Cfematof City.Trywn Date
Pt W,I1J SS ON riv DISPOSF OF SAID DOPY AS STATED ARM/E. i:Title 18. V S A 5201,;
eiuy or Fiiriera Direotor CityTavvri Date
-.3.gedtL.re of Lterratori.;r-i ;•:..enta-'or Numner Bate
, . .
SECTION D: IF BURIAL OR ENTOMBMENT IN VERMONT
Na"r-e of'Cemetery City/Town Date
FFR%liSS GIVEN 7iT: SFOSE OF SAID BiDD'': A S S-A-ED ABOVE iTitie 18 V S A 6201:i
S.qnature of :Cie* 11-11-..r a I Dtrectof :,ty."7Ownry::ati!
Dry cas El Buried ElEntorribect [3ate
I Nurrtei S.r4rYature o SextotvCemetefy
SECTION E: IF REMOVAL FROM STATE
Cemetery. or Place to where nody is being taken City/Tow-, State or Country Date
!cvt rcinalor:, cht,..•cr,',hur\ ,liti I
P SS :71.1,, CIVEN TO S SPOSF SAID HOL'i'• AS STATEL: I itie 18 V S. A 5201:
tfrik Unera IDliecto• Clty'Tovi-
‘4,-4 z
s to ti,...Town Clerk by '"€- 1Cth 'etov.•rig os , oi Tit e 16 V S A