Good, Adam ,
VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH
BURIAL-TRANSIT PERMIT Permit No. 331
Permit for Removal,Disinterment and Renterment
1. Decedent's Name 2. Sex 3.Date of Death
Adam J. Good jmale May 23, 2014
4. City/Town of Death 5. Date of Biiih 6. Place of Birth
ift111, Bennington p/Z7 /°/3O � � �y�y �(/
7.Name and Address of Funeral Director /I
BOP L Gorjor> 1,1/,L.o f01 0 . J 1 12434
PERMISSION REQUESTED FOR: (Cheek only one box and complete the appropriate section 1
a
❑Temporary Storage or Donation(Sdbl bi iil) 0 Cremation(Section C) ❑Burial or Entombment (Section D)
❑Removal From Temporary Storage/Place of Donation or Disinterment (Section B) L$Removal From State(Section E)
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERMONT
� \, Name of Cemetery/Place or Donation Facility City/Town Date
IIIPERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATEDABOVE(Title 18,V.S.A.5201) -
Signature of Clerk/Deputy or Funeral Director I City/Town Date
Signature of Sexton/Cemetery Official or Representative of Organization Receiving Donation Date
• SECTION B: IF REMOVAL FROM TEMPORARY S1 ORAGE/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) .
Signature of Clerk/Deputy or Funeral Director City/Town Date
Signature of Crematorium Official6
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
so
ram. Date
Body was: 0 Buried 0 Entombed '
Section .Lot Number Grave Number Signature of Sexton/Cemetery Official
SECTION E: IF REMOVAL FROM STATE
Name of Cemetery or Place to where body r i`s being taken City/Town,State
+or Country Date
j2 j.n e \I i 1?� e rtn 101 ? BODY AS STATED ABOVE(Title+18hiV.S.A.5201)a5 ! 2, 1 az t
PERMISSION GIVEN TO DISPOSE OF SAID
Signature of Cie eputy or Funer irector 1 City/Town I Date
Bennington May 23, 2014
This permit is to bellied with the City/Town Clerk by the 10 day of the month following disposition.(Title 18 V.S.A.5215)