Larson, Norman -ar�1►
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
Norman Alhp-rt T�qrgoln Male %%hymary2 1
4. City/Town of Death 5. Date of Birth 6. Place of Birth
Rutland December 7 1920 Rutland, Vermont
7. Name and Address of Funeral Director or Authorized Person
Douiz1as V. King, Durfee Funeral Home, Fair Haven, Vermont 057443
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/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 ritylTown --jDate
Signature of Sexton/Cemetery Official Date
SECTION 13: (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
Queenisburyl, New York
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A.5201)
Si a re of Clerk ortgoly City/Town F ate 1992
Rutland
Si a re of rematorium Official Container Number Date
rue, v; e,u/ L e S-- L- 9OIL,
SECTION D: (Complete this section if body/cremains will be buried or entombed.)
Name of Cemetery City/Town 7 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
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)