LeFurgy, Charles S DH-PHS-BTP-89a VERMONT DEPARTMENT OF HEALTH
BURIAL-TRANSIT PERMIT Permit No.
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name(first, middle, last) 2. Sex 3. Date of Death
Charles Sanford LeFurgy Male February 169 1991
4. City/Town of Death 5. Date of Birth 6. Place of Birth
H bbardton
7. Name and Address of Funeral Director or Authorized Person
Douala Doualas V. King, Durfee Funeral Home Fair Haven Vermont 05743
PERMISSION REQUESTED FOR: (Check only one box and complete appropriate section)
❑Temporary ❑Removal from [$Cremation ❑Burial or
Storage Temp. Storage or (Section C) Entombment
(Section A) Disinterment (Section D)
(Section B)
SECTION A: (if temporary storage, complete this section.)
Place of Storage(Name of Cemetery or Vault) City/Fown, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
Signature of Clerk or Deputy CitylTown Date
Signature of Sexton/Cemetery Official 76ate
SECTION B: (If removal from temporary storage or disinterment. complete this section.)
Name of Cemetery or Vault from which body is being removed City/Town Date
Name of Cemetery where body is being taken CitylTown, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
Signature of Clerk or Deputy CitylTown Date
Signature of Sexton/Cemetery Official Date
SECTION C: (Complete this section if body will be cremated.)
Name of Crematorium CitylTown, State Date
Pine View Crematory Queensbury, New York 2/18/91
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
!� Sign of Cl or Degty CityfTown Date
1 uz L , i
Signs ure of ematorium Offi 'al Container Number Date
SECTION D: (Complete this section if body/cremains will be buried or entombed.)
Name of Cemetery City/Iown Date
m wtoe,7 b `O _ y-"i1
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A. 5201)
• Signature of Clerk or Deputy CitylTown Date
Body/Cremains were ❑Buried ❑ Entombed Date
Name of Cemetery Section Lot Number Grave Number
City/Town, State Signature of Sexton/Cemetery Official
This permit is to be filed with the City/Town Clerk by the 10th day of the month following disposition. (Title 18, V.S.A. 5215)