Fish, Gaylord S DH-PHS-5TP-- 3`a VERMONT DEPARTMENT OF HEALTH
BURIAL-TRANSIT PERMIT Permit No.
Permit for Removal, Disinterment and Reinterment
1.Decedent's Name(fir t, middle, last) r 2. Sex 3. Date of Death
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04
/- 1,311,991
4. C'y own of Death 5. Date of Birth 6. Place of Birth .17
7 Ame and Address of Funeral Djirector or Authorized Person
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ERMISSION REQUESTED FOR:(Check only one box and complete appropriate section)
❑Temporary ❑Removal from Q Cremation ElBurial 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/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
• • • •• . • .•- • • • • - •
Name of Cemetery or Vault from which body is being removed City/Town Date
Name of Cemetery where body is being taken City/Town, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A. 5201)
Signature of Clerk or Deputy City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION C: (Complete this section if body will be cremated.)
e of Cr matorium City own, State Date
t /7C l
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED AB ME. (Title 18, .S.A. 5201)
S ature of Clerk or Depty City/Town Date
/3 /571
ignat�re f Cre at ium Offici Container Number D e
SECTION D: (Complete this section if body/cremains will be buried or entombed.)
Name of Cemetery City/Town Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A. 5201)
• Signature of Clerk or Deputy City own 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)