Roberts, Howell 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
Howe,-e 7 homaa Ro,e zt,6 (7a ee 14ugu,6t 11, 1999
4. City/Town of Death 5. Date of Birth 6. Place of Birth
Ca,6t /you ftney June 30, 1920
7. Name and Address of Funeral Director or Authorized Person 266 A Uen Ave.
1ame,6 C. Aagirz o/ Rotelztz-Rup-in fune2ae Home Pouitney, V7 05764
PERMISSION REQUESTED FOR:(Check only one box and complete appropriate section)
❑Temporary ❑Removal from XXftcremation ❑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/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 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 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.)
Name of Crematorium City/Town, State Date
Pirze View CZematozy QtLeen,6,ku2 New o2k �Aujq. 12 199
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
nature of Cl/e or Deputy City/Town Date
C�• 15-&c4e�e, -
i nature of Crema rium Offici Container Nu ate
I- l
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 Citylfown 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)