Feeney, Marjorie 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
Marjorie McHugh Feeney Female December 1 , 1995
• 4.Cityrrown of Death 5. Date of Birth 6. Place of Birth
Rutland June 5, 1914 New York City, New York
7. Name and Address of Funeral Director or Authorized Person
Jim Aubin Roberts—Rubin Funeral Home 17 Allen Ave. ,Ppultney,Vt .
PERMISSION REQUESTED FOR:(Check only one box and complete appropriate section)
❑Temporary ❑Removal from XXCremation ❑Burial or
Storage Temp. Storage or (Section C) Entombment
(Section A) Disinterment (Section D)
• (Section B)
SECTIO porary storage. • •
Place of Storage(Name of Cemetery or Vault) Citylfown, 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 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 Cirylfown Date
Signature of Sexton/Cemetery Official Date
SECTIO omplete this sectionbody will •-
Name of Crematorium City/Town, State Date
Pine View Crematorium Queensbury, New York Dec. 4, 199
PERMISS19,10 IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
• Signatur Clerk or D CitylTo D to
r �
Sig r of r i m Offici Contai er um er ,t Date
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)