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VDH-HSI-BTP-2023 ERMONT DEPARTMENT OF HEALTH Permit No.
` BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1.Decedent's Name 2. Sex 3. Date of Death
Marie P. Shaw Female October 17, 2023
4.City/Town of Death 5. Date of Birth 6.Place of Birth
Bennington March 7, 1926 North Bergen,NJ
7. Name and Address of Funeral Director
Jon W. French, Singleton, Sullivan Potter Funeral Home,407 Bay Road Queensbury,NY 12804
PERMISSION REQUESTED FOR: (Check only one box and complete the appropriate section)
El Temporary Storage or Donation(Section A) 0 Cremation or NOR(Section C) 0 Burial or Entombment(Section D)
El 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
P`n/e ii,`e,,tJ CrPinA -I-DrA a"eeaSkir /0-e/-ze43
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PERMISSION GIVEN TO DISPOSE OF SAID BC AS STATED ABOVE(Title 18,V.S.A. 5201)
Signature of Clerk/Deputy or Funeral Director City/Town Date
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Signature of Dis•;siti. F. ility Official Container Number 8/ Date
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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 Crematorium Quecnsbury,NY October 19,2023
PERMISSION IVE r,• DISPOSE OF SAID BODY AS STATED ABOVE(Title 18,V.S.A.5201)
Signature of Ierk/r.;/ut or Funeral Director
i'� ICity/Town
FEAIN.ritt ray //r,. IDAe
e /9/2023
T is .-r it 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)
Receipt
Human remains of delivered on , 20
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Pine View Cemetery Representing the funeral home named on burial permit
Official Funeral Directors Reg.or License#