Moyer, Ryne DH-PHS-13TP-89a VERMONT DEPARTMENT OF HEALTH
BURIAL-TRANSIT PERMIT Permit No.
Permit for Removal, Disinterment and Reinterment
1. D edent's Name(first, middle, last) 2. Sex 3. Date of Death
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• 4. ityfTown of Death 5. Date of Birth 6. Pjjace of Birth
,C PG/7/ iUC•U a�'� D 2�. 7, 9F 7 .1,��Ts�Bfl // « a.P.r
7. Name and Address of Funeral Director or Authorize Person D 0
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PERMISSION REQUESTED FOR:(Check only one box and complete appropriate section)
❑Temporary Aiemoval from 'Cremation ❑Burial or
Storage Temp. Storage or (Section C) Entombment
(Section A) Disinterment (Section D)
(Section B)
SECTIO orary storage. • •
Place of Storage(Name of Cemetery or Vault) frown, State Date
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18,V.S.A. 5201)
Signature of Clerk or Deputy ri /Town Date
Signature of Sexton/Cemetery Official Date
SECTION 13� (If removal from ternporary storage or disinterment. complete this secton.)
Narne of Cemetery or Vault from which body is being removed City/Town Date
e s.-fr.v r' l x-r--lo �-,'Yvawerzwll sff'P�,uca� 'T s /ors'
'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)
Siq ature of Clem or Deputy CitylTQwn �tg
�! y� s-
g ure of exton/ tery 'cial Date
SECTIO omplete this section • be
Na a of Crematorium City/Town,State Date
pl,ve Uf ev L41e0hiM44/41y u ee4S' 11X &e&/ e"ew
PERMISSION IS GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE. (Title 18, V.S.A. 5201) f
• SIVPture of Cler or Dppu _ CitylTown Date
S/
ig re of Cre orium Official Container Number Date
SECTION • • •• or •
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 Citylfown 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)