Couhig, Merlin 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 73.7Dateof Death
Merlin J se Co Mal At 17, 1992
4. City/Town of Death 5. Date of Birth 6. Place of Birth
March 25. 1909 Bathurst. New Brunswick
7. Name and Address of Funeral Director or Authorized Person
Douglas V. King, Durfee Funeral Herrie, Fair Haven Vermont 05743
PERMISSION REQUESTED FOR:(Check only one box and complete appropriate section)
❑Temporary ❑Removal from M 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 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 CitylTown, State Date
Pine View Crematory Queensbury, New York 8 17 92
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A. 5201)
• Signipture of Cler r De City/Town Date
G Rutland 8 1 2
Si n t e of Crema ium Wicial Container Number Date
a�
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/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)