Ellis, Raymond 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
Raymond Arthur Ellis Male December 4 1999
4. City/Town of Death 5. Date of Birth 6. Place of Birth
luanuary8 1923 Castleton, VT
7. Name and Address of Funeral Director or Authorized Person
James Aubin 119 North Main Street Fair Haven, VT
PERMISSION REQUESTED FOR: (Check only one box and complete appropriate section)
❑Temporary ❑Removal from 37 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 Cit Own 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 CitylTown 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 Citylfown, State Date
CrematoryPine View NY �12/06/1999_.
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
nature of Cler►y, r De uty CityfTown Date
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Si ture of Cremat(yiuy Offici Container Number Date,- i _ er
SECTION D: (Complete this section if body/cremains will be buried or entombed.)
Name of Cemetery CitylTown 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)