Peterson, Walter - DH-PHS-5B-78
STATE OF VERMONT
BURIAL-TRANSIT PERMIT Permit No. .............................
oOo DECEASED—NAME FIRST MIDDLE LAST SEX DATE OF DEATH(Month,Day,Year)
1 Walter Peterson 2 Male s 3/1/88
RACE—(White,Black, AGE LAST BIRT) UNDER 1 DAY DATE OF BIRTH COUNTY OF DEATH
S
American Indian, �l,te DAY(Year17 DAY HOURS MIN. (:�1tt .,,[ytu*)
4 ETC.(Speczfy) 5A 58 5C 6 �'} (,} 17A Rutland
CITY,
TOWN OF DEATH gHOSPITAL OR OTHER INSTITUTION tit not m either, IF HOSPITAL or INSTITUTli
7B .Rutland 7C tz�e St.eet and N.mh�util d ��rs* .medical Center 170 InPat. ER ❑ C
PERMISSION REQUESTED FOR: t'ac
71 BURIAL CREMATION LJ TEMPORARYSTORAGE
(Complete Item 12 below)
8.
PLACE OF DISPOSITION/Cemetery or Crematory( (CITY OR TOWN) (STATE)
Pine Crematory Glens Falls New york
9.
NAME OF FUNERAL DIRECTOR BUSINESS ADDRESS
Aldous Funeral Home 44 No. main street Rutland, VT 05701
10. 11.
IF TEMPORARY PLACE OF t.tianze o(zauW (CITY OR TOWN) (STATE)
STORAGE,FILL STORAGE
IN THIS SECTION:
12, 12A. 12B. 12C.
PERMISSION IS HEREBY GRANTED TO REMOVE AND DISPOSE OF THE BO DENTIFI ABOV
Signature of clerk or deputy �. CITY OR TOWN DATE
Joseph P. Barnhart, deputy Rutland City 3/3/88
13. 14. 15.
CEMETERY OR CREMATORY AUTHORITIES SHALL FILL OUT SECTIONS BELOW:
BODY WAS. DATE jj�J( / NAM({E OF CEMETERY OR CREMATORY /�.�// /y//� / SECTION LOT NO.
❑ BURIED 18. • r � ( Illir sv "C.� 19. 20.
LOCATION (CITY OR TOWN) (STATE) SIGNATURE OF SEXTON OR
Vim' CREMATED LkW_X,59tJf1
OTHER PERSON IN CHARGE
❑ STORED Ill"'
! ,.
16. 21. / 2