Gudikunst, John VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. Id,
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name 2. Sex 3. Date of Death
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4. City/Town of Death 5. Date of Birth 6. Place of Birth
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7. Name and Address of Funeral Director , ` fit p c9 3-c�3
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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) -emoval From State(Section E)
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERMONT
/� Name of Cemetery/Place or Donation Facility City/Town Date
0
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A. 523
Signature of Clerk/Deputy or Funeral Direcctor CityTfown Dale
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 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 Official Container Number Date
SECTION D: IF BURIAL OR ENTOMBMENT IN VERMONT
410
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
7----. Date
1111 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 is being taken City/Town, State or Country Date
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PER SSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A. 5201)
Sig ure of CI k/D uty or Funeral Director City/Town Date
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This permi is o be filed with the City/Town Clerk by the 10 day of the month following disposition.(Title 18 V.S.A.5215)