Lambert, Theresa OS/23/2013 10:43AhM FAX ++8027737578++++ a 0001/0002
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VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. i1a D
BURIAL TRANSIT PERMIT
Permit for Removal,Disinterment and Reinterment
Ar-1.Decedents Name 2_Sex 3.Date of Death
Theresa R.Lambert Female August 21,2013
4.City/Town of Death 5.Date of Birth 5_ Place of Birth
Rutland City October 06, 1925 Glens Falls,NY
7.Name and Address of Funeral Director
Singleton Sullivan Potter Funeral Home,407 Bay Road,Queensbury,NY 12804
PERMISSION REQUESTED FOR: (Check only one box and complete the appropriate section)
0 Temporary Storage or Donation(Section A) 0 Cremation(Section C) 0 Burial or Entombment(Section 0)
El Removal From Temporary Storage/Place of Donation or Disinterment(Section B) la 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 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 .r Facility from which body is being removed City/Town Date
PERMISSION GIVEN TO E ISPOSE 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 car Funeral Director City/Town Date
signature Of Crematorium Official Container Number Date
SECTION I7; 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: ❑ 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 a where body is being taken City/Town,State or Country Date
Pine View Crematory Queensbury,NY August 23, 2013
PER -lON GIVE TO POSE OF SAID BODY AS STATED ABOVE 'le 18,V.S.A.5201)
Si. = i - of Cie ;f. a a i -.,• !To Date
Adoi
This Fie it is to I ed - t 6 C %/Town Clerk by the 10th y of the month following disposition.(Title 18 V.S.A.5215)