Briggs, Ronald P DH-PHS-BTP-89 DEPARTMENT OF HEALTH PERMIT NO. _ _.. _..................
VERMONT BURIAL-TRANSIT PERMIT
1.DECEDENp�NAME(First,Mid ,Lash 2.SEX 3.DATE OF DEATH(Month.Day.Year)
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4.SOCIAL SEOURITY NUMBER 5a.AGE(Yrs.) Sb.UNDER 1 YEAR Sc.UNDER 1 DAY 6,DATE OF BIR (Month,Day,Year)
—last (Yr
Months Days Hours Minutes
7.BIRTHPLACE(City and State or Foreign Country) 8.PLACE OF DEATH(Check only one)
' HOSPITAL OTHER
❑Inpatient ER/Outpatient ❑DOA ❑ Nursing Home ❑ Residence ❑ Other(Specity)
9.PERMISSION REQUESTED FOR -
❑BURIAL ❑ REMOVAL TO CREMATORIUM ❑ TEMPORARY STORAGE ❑ OTHER
(Complete Item 12 below) (Specify)
10.PLACE OF FINAL DISPOSITION (Cemetery or Crematory) (City or Town) (State) 11 DATE
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IF TEMPORARY STORAGE,FILL IN THIS SEC ION:
12.PLACE OF STORAGE: (Name of Vault) (City or Town) (State) 13.DATE
14.NA OF FUNERAL DIRECTOR 'BUSINESS ADDRESS j� .I T
A certificate of death aving be4offiled as requiredA the laws of this State,permission is hereby given to dispose of said decea stated abdve.
15.SIGNATURE OF CLERK OR DEPU (City or Town) 16. TE
CEMETERY OR CREMATORY AUTHORITIES SHALL FILL OUT SECTIONS BELOW:
18.DATE 19,NAME OF CEMETERY OR CREMATORY 20.SECTION 21.LOT NO,
17.Body was:
71 /1/ r,
;J/CREMATED Cz/
❑STORED 29.COCAT N (City or Town) (State) 23.SIGNATURE OF SEXTON OR OTHER PERSON IN C ARGE
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