Berry, Aline DH-PHS-BTP-89a VERMONT DEPARTMENT OF HEALTH
BURIAL-TRANSIT PERMIT Permit No.
Permit for Removal, Disinterment and Reinterment
1. cedegt's Name girst� last) 2 3. ate l eat s
• 4. Ci�z/Twn of Death 5. Date of Birth 6. Place of Birt
7. arse and A dress of Funeral irector or Authorized Person . (3 / /
RMISSION REQUESTED FOR:(Check only one box and complete appropriate section)
❑Temporary ❑Removal from X-Cremation ❑Burial or
Storage Temp. Storage or (Section C) Entombment
(Section A) Disinterment (Section D)
• (Section B)
SECTION •rary storage. complete •
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 13� (If removal frorn temporary storage or disinterment, complete this section
Name of Cemetery or Vault from which body is being removed 77Town 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 CitylTown Date
Signature of Sexton/Cemetery Official Date
SECTIO plete this section • •-
Na pf Crematorium City n, State Das e
ERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE.4fifie 18,V.K.A. 5201)
Si tore of Clerk r De uty CityfT10 �C Da
gn a of Cr torium Offici Container Numb Date
a6 ..
SECTION (Complete this section if body
Name of Cemetery Citylfown 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)