Belden, Nancy M r-
VDH-PHS-BTP-2011 ERMONT DEPARTMENT OF HEALTH Permit No. tiqv
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name 2. Sex 3. Date of Death
NI ciun Q M. C3elden F 8 - 3-aoa a
4. City/Town of ffeath 5. Date of Birth 6. Place of Birth
LLAndonvi Ile $-aq - 19LI 2
(414) 7. Name and Address of Funeral Director
sti.phe- 1.. 1Zobenccsr, 5cles F14, 535 St.,rnmc k-.., Z+T\5\ u
PERMISSION REQUESTED FOR: (Check only one box and complete the appropriate section)
❑ Temporary Storage or Donation(Section A) ❑ Cremation(Section C) ❑ Burial or Entombment (Section D)
❑ Removal From Temporary Storage/Place of Donation or Disinterment (Section B) i -emoval From State(Section E)
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERMONT
Name of Cemetery/Place or Donation Facility City/Town Date
(4111) PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE (Title 18, V.S.A. 5201)
Signature of Clerk/Deputy or Funeral Director City/Town Date
Signature of Sexton/Cemetery Official or Representative of Organization Receiving Donation Date
SECTION B: IF REMOVAL FROM TEMPORARY STORAGE/PLACE OF DONATION OR DISINTERMENT
Name of Cemetery/Place or Facility from which body is being removed City/Town Date
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18, V.S.A.5201)
Signature of Clerk/Deputy or Funeral Director City/Town Date
Signature of Sexton/Cemetery Official Date
SECTION C: IF CREMATION IN VERMONT
Name of Crematorium City/Town Date
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18, V.S.A.5201)
Signature of Clerk/Deputy or Funeral Director City/Town Date
Signature of Crematorium Official Container Number Date
fl SECTION D: IF BURIAL OR ENTOMBMENT IN VERMONT
Name of Cemetery City/Town Date
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE (Title 18,V.S.A.5201)
Signature of Clerk/Deputy or Funeral Director City/Town Date
Body was: ❑ Buried ❑ Entombed Date
(II) Section Lot Number Grave Number Signature of Sexton/Cemetery Official
SECTION E: IF REMOVAL FROM STATE
Name of Cemetery or Place to where body is being taken City/Town, State or CountiI Date
A l e-x -Icki r F'c ero�Q Name War r cnsbur , ti Y g-y-d 9-
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE (Title T8, V.S.A. 5201)
Sign ure of Clerk/Deputy uneral Dir tor City/Town Date
i// Lyndon v i 112 a-y -aa
This permit is to be fi ed with the City/Town Clerk by the 10/'day of the month following disposition.(Title 18 V.S.A.5215)
1161
i Public Health Law Sec. 4145(2b)
IReceipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home named on burial permit
F neral D. -ctors Re:.or License#