Yanklowitz, MaryJane VDH-HSI-BTP-2023 VERMONT DEPARTMENT OF HEALTH Permit o.
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name 2.Sex 3. Date of Death
Mary Jane Yanklowitz Female May 05,2023
4. City/Town of Death 5. Date of Birth 6. Place of Birth
Bennington July 29, 1937 Glens Falls,NY
7. Name and Address of Funeral Director
Shawn P.Devlin,E.P.Mahar and Son Funeral Home Inc.,628 Main Street Bennington,VT 05201
PERMISSION REQUESTED FOR:(Check only one box and complete the appropriate section)
[� Temporary Storage or Donation(Section A) [] Cremation or NOR(Section C) Burial or Entombment(Section D)
0 Removal from Temporary Storage/Place of Donation or Disinterment(Section B) ® Removal from State(Section E)
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERMONT
Name of Cemetery/Place or Donation Facility 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 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 OR NATURAL ORGANIC REDUCTION(NOR) IN VERMONT
Name of Disposition Facility 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 Disposition Facility Official Container Number Date
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
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 Country Date
Pine View Cemetery Queensbury,NY May 09,2023
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A.5201)
Signature of Clerk/Deputy or Funeral Director ICity/Town 1Date
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)
Public Health Law Sec. 4145(2b) 012980
Receipt
Human remains of delivered on , 20
F I
Pino iew Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#
YANKLOWITZ
Lot No. Il 1-I
Address 52 Lamplighter Acres , Fort Edward NY 12828 Section No.
Owner MaryJane Yanklowitz Plot Horicon
Date 8/17/04
Approx. 67 Superficial ft.
Location Bounded on North by Weinberg, South by Vacant , East by Shepard,
West by Vacant.
Corner Posts
Remarks
Deed No. (and changes) 3312
Payment Record Paid in Full 8/17/04 )$1 ,000.00)
Record of Interments 57 7 5 )3
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Long . lQSy_ 3051 - p1---. w
Form No. 01
Yanklowitz �"
NAME MaryJane Yanklowitz ge: 85
Lot Owner: MaryJane Yanklowitz
Lot# Horicon 1 I Grave# 1
Case: Concrete
Died: 5.5.2 3 Interred: 5.9 .2 3
Funeral Home: Regan Denny Stafford
Cemetery: Pine View