Anderson Jr, Richard DH-PHS-BTP-89a VERMONT DEPARTMENT OF HEALTH
BURIAL-TRANSIT PERMIT Permit No.
Permit for Removal, Disinterment and Reinterment
1. De edent's Na a(first, middle, last) A 2. Sex 3. Date of Death
L, Nders'ov Tr A*/. e zY
• 4. City/T wn 9gf Deap 5. Datepf Birth 6. Place of Birth
7. Nam nfi Address of Funeral Dire for or Authoriz d Person
O i NJ r/ .ti-�°� � C 2 vr'G�i Cv✓'1•U✓i(/C
PERMISSION REQUESTED FOR:(Che k 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 ••rary 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 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 F6iIyTown Date
Signature of Sexton/Cemetery Official Date
NaSECTION C: (Complete this section if body will be cremated.)
of Cremators City/Town, State Date
iv e i
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED AA0VE. (Title 18, V.S.A. 5201)
Sign re of Clerk or De y city/T Date
,7�� Z/ems �
=of CrerpVorium'—Offid4j Container Number 14 Date
zeq
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 CityfTown Clerk by the 10th day of the month following disposition. (Title 18, V.S.A. 5215)