Shepard, William J -
BURIAL TRANSIT REMOVAL PERMrt „, I DATE ISSUED
VS-9 Rev.2/09 STATE OF CONNECTICUT I
02 / 03 /2022
DEPARTMENT OF PUBLIC HEALTH
HARTFb432,CT 06134-0308
1. This permit is sufficient for the removal of a body to any town and also for inte-Anent. It must accompany the body and be given to the perso-r urge of the cemetery.
2. This permit is NOT sufficient to cremate a body.A Cremation Permit(VS-48)must also be obtained in addition to this permit.
3. The sexton must endorse this permit and return it to the registrar of the town where the cemetery is located.The sexton must also forward a copy of this permit to the town where
death occurred if different from the town of burial. If the body is cremated,the person in charge of the crematory must return this burial permit to the town where death occurred.
PERMISSION IS GRANTED TO REMOVE TRANSPORT/BURY THE BODY OF WtigIalaFRATF 1 9r RN Jq Rf ) ON
William J.Shepard Durham,CT 06422 02 / 03 /2022
CAUSE OF DEATH
Cardiopulmonary Arrest
TEMPORARY DISPOSITION(LOCATION.ADDRESS.CITY.STATE AND TELEPHONE NUMBER)If body placed in receiving vault,give date.
FIN^ DISPDSITION(Name and address of cemetery or crematory)
ii, g06000004millecoud5ococ00c Pine View Crematorys Queensbury, NY
BURIAL PLOT SECTION NO. LOT NO. GRAVE NO. OTHER PLACE OF INTERMENT(Specify)
ISSUED TO(Name of Funeral Director or Embalmer) ADDRESS IF EMBALMER,LICENSE NO.
David MacDonald Wallingford Funeral Home 809 N.Main Street,Wallingford,CT 06492 CT#2530
Certificates required by state statute have been SIGNED(Registrar of Vital Statistics) TOWN OF TRANSIT PASTER
received and recorded.Body has been prepared /� ,-
in accordance with the Public Health Code. i �,/:-',]' v L: )��,/V1 f/1 0 YES 0 NO
THE BODY FOR WHICH THIS PERMIT WAS ISSUED WAS BURIED IN ABOVE NAMED DATE BODY BURIED
SEXTON'S ENDORSEMENT CEMETERY(Sexton's Signature)
Atli uTermW SFt4;re.S l /
� c
Public Health Law Sec. 4145(2b) ` -• "
Receipt
Human remains of delivered on , 20
Pine View-eemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#