Perry, Hazel j!ii mi 14 UV.i ci 0-tILIULlb r ra. ot.I�-r;..1-n as N., '
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VDH-PHS BTP-2C11 VERMONT DEPARTMENT OF HEALTH Permit No ____3�7 1_
BURIAL-TRANSIT PERMIT
Perm It for Rerncvel, Disinterment and Reinterrner t
1. Decedent's Name 2 vex 13. Date of Deaf'I Liz:A A. Perry F011r11e 1.1:II!, I4. 201'
4 :yfrown of Death t Dete of Birth �6 P ace of Biih
".,a�tleti'ri ugust 3f1. 1917 lBrandon. V l'
II17.Name and Aodross of Funeral Di,eetar
,Iiik Din I'uncrai HCtrna, 4 \'lilli.ttns 'ticrvet, Whitehall, NY I2t!1S'
PERMISSION REQUESTED FOR (check orly fine Dox and complete;he approonete sect on;
0 l'cnpo y Storage or Donation lSecxian A) �:'Bmatcr i8e.vor C) 0 F�rat�r Frt;a ym4rn.?5�rtirr:1
i; �
I,]Remouai From Turnporary Storage/Place of D.natio,or Cisintel-!eni iI3ection aj 10 Remove!From S4zie(Sedivn E")
SEGTlON A: if TEMPORARY STORAGE.'OR DONATION IN VIRMONl'
Name of Ca:netery/Pbace ar Donation Facility C ty/Town Date
•
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S A.5201 i
Signature of Cle-kiDeputy or Funeral Director IC ty/Town Date
t
Siq sr lre of SSexton/C6ia 2tr ry Official or Repress fiat ve of O gar'ization Receiving Dona t 4n Date
SECTION B' IF REMOVAL PROM TEMPORARY STORAGE/PLACE Of DONATION OR DISINTERMENT
Name of Cernotetyiplace or Facility from which toady 5 being removed City/Town Date
1
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE?Title 18 V S A 520:1
Signature gf C!®rk/Deputy ar Farrel Director CityfTcwrs Date u "
Sig of SextoniCemetery Official I Date
1
SECT ON C;IF CREMATION IN VERMONT •
Name of Crematorium vityiTown ,Date
i
L
PERMiSsION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S A 5201 i
;Signature of Cie-kfDept;rr o-Funeral Director ICi'yi1owri I Date
I
Signature or Crematorium Officol Container Nun1 er 1}Date _
iE
SECTION I) If BURIAL OR EN tOMEiNtNT IN VFRMONT
Name of Cemetery City/Town I Date
I I
PFRMiS»ION(GIVEN TO DISPOSE C.F SAID SODY AS STATED ABOVE(Title 18,V.S./A 5 0 _____
Signature of Clerk/Deputy or Furierel Director City/Town I Date
r Rudy w„t, 0 Gt-rrPd E Entombod Daie
'Section 'Lot N,mber IGrave Numtaar Signetire of SexIontCerneteory Official
I
SECTION E:IF REMOVAL FROM STATE
9Neme of Cemetery or Pietas to where body is being taken City,Town. Starr-t r Cn:,nfry Oen.
i!I'uac Viev.. Crematorium Queensaurv,NY iJ1i1y 16, 20i2
I PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE:(Tife1! t, V S.A.6201)
i Signature or Furl Direc City;Town Date
TN.::porrnit i>s�p�3.T o�'filed with IPA°City!Tnwr Clerk by the IOth clay of the month following disposition ',Talc 13 V.'I.A.t:.21 t)