Eldridge, Esther r/�c• ai
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
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• 4.Ci ow f Death 5. Date of Birth 6. Place of Birth
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7. Name and Address of Funeral Director or Authorized erson
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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 Ai (If temporary • • •
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 7Date
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 7ate -
SECTIO omplete this sectionbody will • cremated )
-
Npe of Cremator' m own, a Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
Si ature of Cler or D puty ` City/Town Date
f�
ign t of Cre tonum Official -1 Container Number Date
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SECTI
• . - be buried .-
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)