Sampson, Lorenzo, Everette ,
VDH-HSI-BTP-2023 VERMONT DEPARTMENT OF HEALT Permit No. 4f Z I
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1.Decedent's Name 2.Sex 3. Date of Death
Lorenzo Everette Sampson Male October 09, 2023
4.City/Town of Death 5. Date of Birth 6.Place of Birth
Rutland City September 1 , 1962 Bellamy,AL
rill) 7.Name and Address of Funeral Director
Christopher J.Book,Carlton Funeral Home,P.O.Box 67 Hudson Falls,NY 12839
PERMISSION REQUESTED FOR: (Check only one box and complete the appropriate section)
Temporary Storage or Donation(Section A) El Cremation or NOR(Section C) Ei 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
rio) 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
u .1
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 ICity/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
,,)e- V:le i,J f re-,ij J► i'-( Q..ee,As6 L %a/r ZOI5
PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S. 5201)
Signature of Clerk/Deputy or Funeral Director City/Town Date
Signature of Disposition Facility Official i/ Contai Z4 tuber Date y
SECTION D: IF BURIAL OR ENTOMBMENT IN VERMONT
rift)
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
(11141)
SECTION E: IF REMOVAL FROM STATE
Name of Cemetery or Place to where body is being taken City/Town,State or Country Date
Pineview Crematory Queensbury,NY October 13, 2023
PERMISSION GI TO DISPOSE OF SAID Be' AS STATED ABOVE(Title 18,V.S.A.5201)
Sign a erk/Deputy or Fu al Direc •-,--v 1Ciwn/ Date f-
Thi it is to be"filed with th- ity/Town Clerk by the 10th day of the month following disposition.(Title 18 V.S.A.5215)
Public Health Law Sec. 4145(2b) 7 3 a
Receipt
Human remains of delivered on , 20
Pine View Cemetery representing the funeral home named onburi,al.permit
Official Funeral Directors Reg.or License#