Breitenbach, Deborah VDH-PHS BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No.
BURIAL-TRANSIT PERMIT
Permit for Removal,Disinterment and Reinterment
1. Decedent's Name 2. Sex 3.Date of Death
Deborah Anita Jones Breitenbach Female April 22,2014
4.City/Town of Death 5. Date of Birth 6. Place of Birth
Burlington February 11, 1954 Malaysia
r
III 7. Name and Address of Funeral Director
Wilcox&Regan Funeral Home, 11 Algonkin St.,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) 0 Cremation(Section C) 0 Burial or Entombment(Section D)
❑ Removal From Temporary Storage/Place of Donation or Disinterment(Section B) E(Removal From State(Section E)
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERMONT
Name of Cemetery/Place or Donation Facility City/Town Date
IIII PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(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 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 1Date
Body was: 0 Buried 0 Entombed Date
elSection 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 April 25, 2014
PE'if SION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A.5201)
Si. r- .f Clerk/De uunneerral Director ICit own Date
,1/ -.. p ee_,,, ; \' y 6"�'C�/�� ' I ( - y
/ 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)