L

19. FATHERS SOCIAL SECURITY NUMBER 18 'MOTHER'S SOCIAL SECURITY NUMBER:

INFORMATION-FOR MFDICAL AND HEALTH PURP SES ONLY

MOTHER 14. MOTHERS MAIUNG ADDRESS: 9 Same as residence, or State:

Street &Number. Zip Code:

City, Town, or Location:

Apartment No.:

15. MOTHERAARRIED? (At birth, conception, or any time between) IF NO, HAS PATERNITY ACKNOWLEDGEMENT BEEN SIGNED IN THE HOSPITAL? o Yes No

16. SOCIAL SECURITY NUMBER REQUESTED FC/R CHILD?' o YeS, o No

o Ye ,p No 17. FACILITY ID. (NPI)

20. MOTHER'S EDUCATION (Check the box.that best describes the highest degreibr level of school completed at the time of delivery)

o Sthgradeorless

o 9th -12th grade, no diploma

o High sciibol graduate or GED completed

o Some college credit but no degree

o Associate degree (e.g., AA, AS)

o Bachelor's degree (e.g., BA, AS, BS)

o Master's degree (e.g., MA, MS, MEng," MEd, MSW, MBA)

o Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DOS, DVM, (.LB, JD)

21. MOTHER OF HISPANIC ORIGIN? (Check the box that best describes whether the molherls Spanish/HIspanic/Latina. Check the "No' box if mother Is not SpanfshIllispanic/Latina)

o No, not Spanish/Hispanickatina

o Yes, Mexican, MeAcartArnerican, Chicane

a Yes, Puerto Rican

• Yes, Cuban

o Yes, other Spanish/Hispanic/Latina

(Specify)

22. MOTHER'S RACE (Check one or mom races to indicate what thelnother considers herself to be)

o White o Black or African Arnericen o ivnerfean Or,,Alaska Native

(Name of the enrolled Or principal tribe) o Asian Indian o Chinese o Mllpfno o Japanese o Kohilan o Vietnamese o Other Aston (Speedy) O Native Hawaiian o Guamanian or Chamorro o Samoan o Other Pacific Islander (Specify) o Other (Specify) '

ITOTHERI

23. FATHER'S EDUCATION (Check the box that best describes the highest degree or level of school completed at the time of delivery)

o 8th grade or less

o 9th - 12th grade, no diploma

o High school graduate or GED completed '

o Some cortege credit but no degree

q Associate degree (e.g., AA, AS)

o Bachelor's degree (e.g., BA, AS, BS)

o Master's degree (e.g.', MA, MS, MEng, MEd, VISW, MBA)

o Doctorate (ag., PhD, EdD) or Professional degree (e.g., MD, DOS, DVM,ILB, JD)

24. FATHER OF HISPANIC ORIGIN? (Check the box that best describes whetherthe father Is Spanish/Hispanic/Latino, Check the No box If father is not SpanIshfilispanic/Lafino)

o No, not SpanisidHispanic./Latino

o Yes, MeAcan, Mexican American, Chicano

o Yes, Puerto Rican

o Yes, Cuban

o Yes, other Spanish/HIspanicAatino

(Specify)

25. FATHER'S RACE (Check one or more races to indicate what the father considers himself to be)

o VVhite o Black or African American o American Indian or Alaska Native

(Name of the enrolled or principal tribe) o AS11111 Indian o Chinese

o Japanese o Korean o Vietnamese o Oths'ir Asian (Specify) o Native Hawaiian o Guarninlan'Or Chamorro o Samoan o Other Pacific Islander (Specify)

o Other (Specify)

Mot

he

r's

Nam

e

26. PLACE WHERE BIRTH OCCURRED (Check one) o Hodpital

a Freestanding birthing canter o Home Birth: Planned to deliver at home? 9 Yes 9 No o Clinfrilbociorit 'bfficer

o Other (Specify)

27. ATTENDANTS NAME, TITLE, AND NPI

NAME: NPI:

TITLE: o MD o DO o CNMICM a OTHER MIDWIFE

o OTHER (Specify)

28. MOTHER TRANSFERRED FOR MATERNAL MEDICAL OR FETAL INDICATIONS OR DELIVERY? in Yes a No IF YES, ENTER NAME OF FACILITY MOTHER TRANSFERRED FROM:

REV. 1112003

U.S. STANDARD CERTIFICATE OF UVE BIRTH LOCAL FILE No

BIRTH NUMBER:

{C H I L 1. CHILD'S NAME (First, Middle, Last, Suffix) 2. TIME OF BIRTH (24 hr)

3, SEX 4. DATE OF BIRTH (Mo/Day/Yr)

5. FACILITY NAME Of not Institution, give street and number) 6. CITY, TOWN, OR LOCATION OF BIRTH 7. COUNTY OF BIRTH

Fiv-i cyfifirrstior 8a. MOTHERS CURRENT LEGAL NAME (Flrst, Middle, Last, Suffix) 8b. DATE OF BIRTH (Mo/Day/Yr)

8c, MOTHERS NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last, Suffix) 8d. BIRTHPLACE (State, Territory, or Foreign Country)

9a, RESIDENCE OF MOTHER-STATE 913. COUNTY Do CITY, TOWN, OR LOCATION

- 9cL STREET AND NUMBER • 9e. APT NO. 9f. ZIP CODE 9g. INSILJO 1...11Y UMITS?

o Yes o No

FATHER 1.0e. FATHER'S CURRENT LEGAL NAME (First, Mike, Last, Suffix) lab. DATE OF BIRTH (Me/Day/Y1) - 10c. BIRTHPLACE (State, Tentery, or ,i31331tin Country)

11. CERTIFIERS NAME: 12: DATE CERTIFIED 13. DATE FILED BY REGISTRAR , CERTIFIER TITLE: o MD o DO a HOSPITAL ADMIN. o CNM/CM o OTHER MIDWIFE I / _I.__/

a OTHER (Specify) MM OD YYYY MM DD YYYY i

MEL

Mot

her

's N

ame

'At

MOTHER 19a.. DATE OF FIRST PRENATAL CARE yisir ci No Prenatal Care

MM DO YYYY

29b. DATE OF LAST PRENATAL CARE VISIT

MM DD YYYY

30. TOTAL NUMBER OF PRENATAL VISITS FOR THIS PREGNANCY

(If none, enters0".)

31. MOTHER'S HEIGHT (feetrinches)

32. MOTHERS PREPREGNANCY WEIGHT (pounds)

33. MOTHERS WEIGHT AT DEUVERY (pounds)

34. DID MOTHER GET WIC FOOD FOR HERSELF DURING THIS PREGNANCY? a Yes o No

35. NUMBER OF PREVIOUS LIVE BIRTHS (Do not include this child)

36. NUMBER OFOTHER - PREGNANCY OUTCOMES (spontaneous or Induced losses orectopic pregnancies).

35a: Now Living

Number

a None

35b, Now Dead

Number

o None

38a. Other Outcomes

Number

o None

37. CIGARETTE SMOKING BEFORE AND DURING PREGNANCY For each time period, enter eitherthe number of cigarettes or the number of packs of cigarettes smoked. IF NONE, ENTER s0".

Average number of cigarettes or packs of cigarettes Smoked per day. # of cigarettes # of packs

Three Months Before pregnancy OR First Three Months or Pregnancy [ OR Second Three Months of Pregnancy OR Third Trimester of Pregnancy OR

38. PRINCIPAL SOURCE OF PAYMENT FOR THIS Alaters, [DELIVERY

o Private Insurance n Medicaid o Self-pay o Other

(Specify)

35c. DATE OF LAST LIVE BIRTH

MM YYYY

36b. DATE OF LAST OTHER PREGNANCY OUTCOME

MM YYYY

39. DATE LAST NORMAL MENSES BEGAN

MM DO YYYY

40. MOTHER'S MEDICAL RECORD NUMBER

r MEDICAL AND

HEALTH INFORMATION

41. RISK FACTORS IN THIS PREGNANCY , (Check all that apply)

Diabetes o Prepregnancy (Diagnosis prior to this pregnancy)

!

o Gestational (Diagnosis in this pregnancy)

Hypertension o Prepre`gnancy pro' nic) ci Pasiatinnal ,(P11-1, Prelidarnasia) o Edampsla

a Previous pretetm birth

o Other pro' vieus poof'aregnancy outcome(InCludes , perinetalqeatt Small-for-gestation0 age/Intrauterine

growth restricted birth)

o Pregnancy resulted from infertility treatment-If yes, cheds aft that ap-plyi o Fertility-enhancing drugs, Artificial Insemination Of

Intrauterine Insemination a Assisted reproductive technology (e.g., in vitro

fertilization INF), gamete Intrafalloplan transfer '(GIFT))

o Mother had a previges cesarean delivery If yes, how many

o None of the above 42. INFECTIONS PRESENT AND/OR TREATED

DURING THIS PREGNANCY (Check all that apply)

o Gonorrhea a Syphilis o Chlamydia o Hepatitis B o Hepatitis C o None of the above

43. ZOBSTETRIC PROCEDURES (Check all that apply)

o Cervical cerclage o Tocolysis

External cephalic version: o Successful o railed

o None of the above

14. ONSET OF LABOR (Check all that apply)

o Premature Rupture of the Membranes (prolonged, 312 hrs.)

o Precipitous Labor (<3 hrs.)

ci Prolonged LeibiSr (320 hrs.)

C None of the above

45. CHARACTERISTICS OF LABOR AND DEU VERY (Check all that apply)

o Induction of labor o Augmentation of labor o Non-vertex presentation o Steroids (glococerticolds)forfetal lung maturation

received by the mother prior to delivery ci Antibiotics receive'd by the mother during labor o Clinical chorloamdonkis diagnosed during labor or

maternal temperature >38•C (100.4T) a Moderate/heavy meconium staining of the amniotic fluid o Fetal intolerance of labor such that one or more of the

following actions was taken: In-utero resuscitative measures, further fetal assessment, or operative delivery

o Epidural or spinal anesthesia during labor o None of the above

46. METHOD OF DELIVERY

A. Was delivery with forceps attempted but unsuccessful?

o yes o No

B. Was delivery with vacuum extraction attempted but unsuccessful?

p Yes o No

C. Fetal presentation attsirth o CePhalic n Broads o Other

b. Firtalienta and method of delivery (Check one) a Vaginal/Spontaneous o VaginaUFon-wa o. VaginaiNacinin o •Ceisirean'

If cesarean was a trial of labor attempted? o

o No

47. MATERNAL MORBIDITY (Check all that apply) (Complications asseciated with labor and delivery)

o Mateniatiransfuslon o Third or fourth degree perinea! laceration

VRtipttired uterus a Unplanned hysterectomy o Admission to intensive care unit o Unplanned operating room procedure

following delivery a None'of the above

NEWBORN1048. NEWBORN MEDICAL RECORD NUMBER

50. OBSTETRIC ESTIMATE OF GESTATION:

(completed weeks)

51. APGAR SCORE: Score at 5 minutes - if 5 nilinine sca-rits less than 6,

Score at 10 minutes:

NEWBORN INFORMATION 54. ABNORMAL CONDITIONS OF THE NEWBORN

(Check all that apply)

a Assisted ventilation required immediately following delivery

o Assisted ventilation required for more than six hours

o NICU admission

a Newborn given surfactant replacement therapy

o Antiblotica,receivad by the newborn- for suspected neonatal sepsis

a Saloons or serious neurologic dysfunction

o Significant birth Injury (skeletal fracture(s), peripheral nerve irqury, and/or soft tissue/solid man hemorrhage which requires Intervention)

9 None of the above

55. CONGENITAL ANOMAUES OF THE NEWBORN (Check all that apply)

o Anencephaly o Meningoenyelocele/Spina bifida a Cyanotic congenital heart' disease o Congenital diaphragmatic hernia o Omphalvele o Gastroaditais a Limb reduction defect (excluding congenital

atrroutation and dwarfing syndrome's) o CleftlJfirWith grwithout Cleft Palate o Cleft Palate alone o Down Syndrome -

o KiryolYpe confirmed ci Karyotype pending

a Suspected chromosomal disorder ci KeryotYpe confirmed o Karyotype Pending

o Hypospatilis o None of the anomalies listed above

49. BIRTHVVEIGHT (grams preferred, specify unit)

9 grams 9 !Woo

52. PLURAUTY- Single, Twin, Triplet, etc

(Specify)

53. IF NOT SINGLE BIRTH - Born First, Second,

Third, etc. (Specify)

56. WAS INFANT TRANSFERRED WITHIN 24 HOURS OF DELIVERY? 9 Yes 9 No IF YES, NAME OF FACILITY INFANT TRANSFERRED

TO:

57. IS INFANT UV1NG AT TIME OF REPORT? o Yes o No o Infant transferred, status unknown

58. IS THE INFANT BEING BREASTFED AT DISCHARGE?

o Yes o No

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VERMONT. OEPARTMENT OF HEALTH '

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- 173

VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH BURIAL-TRANSIT PERMIT

Permit for Remove, Disinterment and Reinterrnept

Permit No.

1, Decedent's Maine 12. Sex 3. Date of Death

4. City/Town of Death 5. Date of B rth j6/ie 5fElrth

7. Name and Address of Funeral Director _

PERMISSION REQUESTED FOR: (Check only one box -

an,icomplete -V

the appropriE,te section) • Temporary Storage or DonaGon (Section A) El Cremation (Section C) • Burial or Entombment (Section CI)

1:1 Removal From Temporary Storage/Place of Donation or Disinterment (Sector B) iii Reprove! 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 Cityffown Date

PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE (Title 13, 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

Mount Anthony Cremation Services, Inc.

City/Town Benuing,ton

Date June 20, 2016

PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE (Title IS, V.S.A. 5201) Signature of CI rk/Deputy or FL neral . tor City/Town Date ,

..7,,,,t Signature-Of Crematorium Official /

, ir

Cont. n-r NuTber

/02

Date

....m.....,-__..........wy-.- Ao ... SECTION D: IF BURIAL OR ENTOMBMENT IN VERMONT

/ k.7i,-.17 e - 6' Vol

Name Of Cemetenj City/Town Date

PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED Ai3OVE T1tle 18, V S.A. 5201) Signature of Clerk/Deputy or Funeral Director . City/Town Date

Body was: D Buried 0 Entombed Date

Section

SECTION E: IF REMOVAL

Lot Number

FROM STATE'

Grave Number Signature of Sexton/Cemetery Official

Name of Cemetery or Place to where body is being taken City/Town, State or Country Date

PERMISSION GIVEN TO DISPOSE OF SAID BODY AS STATED ABOVE (Title 8. V.S.A. 5201j Signature of Clerk/Deputy or Funeral Director City/Town Date

This permit is to bellied with the City/Town Clerk by the 10th day of the month following disposition. (Title 18 V.S.A. 5215)

EITP-FET.09 VERMONT DEPARTMENT OF HEALTH

BURIAL. TRANSIT - DISPOSMON PERMIT FOR FETAL REMAINS

FETUS., _ ,,.,,_.

FETUS-NAME FRIST(II given) worm F itl Om) LAS f

._ _

' - • LiVEri Y (Mmtli, nuy. ycer) HOUR ATE D

a. TOWN OF DELIVERY

2o,

MOSPFFAL -NAME ! rwt In t'opItat, - ,va simet afvi nurnber

SEX

0 MALE

0 ntAALE 0 UNKNOWN

&

L VERY:

0 TWW

°sinus 0 TRIPLET

0

Eds7 mEl sT BORN

- Chl-itHD

R EIG . DID FETUS DIE?

OUEFORE LABOR ODURMG LABOR

CR DELIVERY OUNKNOWN

PARENTS 7a. MOTHER'S NAME (First Middle. & DATE OF BIRTH (Month, Day, Year) Leal) 7b. MAIDEN SURNAME

9a: RESIDENCE-STATE leb_. CITY Oft TOWN 10. BIRTHPLACE (State or Foreign Country) .

11. MOTHER'S MAILING ADDRESS. (Sawn and Nurnbor or Flural Route Number, City or Town, State, Zip Code)

12. FATHER'S NAME (First. Middle. Lea0

AUTHORITY FOR DISPOSITION:

This permit-, when completed fying physician, constitutes of the fetal remains V. 5..A.)

CEMETERY SEXTON OR COMMERCIAL

-Complete the bottom Clerk on a monthly basis (Title 18, 5224 (b),

13. DATE OF BIRTH (Month, NY. Year)

and bearing the name authority for final

identified above. (Title

CREMATORY:

line, and deliver to the Town with other burial-transit

V. S. A.)

14.. BIRTHPLACE (plate or Foreign Country)

of a certi-disposition

18, 5224 a),

or City perMits.

,.(2,RTIFIER

Neme of Certifying Physician .

•

b...:4-

Date,Completed .

' CERTIFIER-MAILING ADDRESS (Strad or R.F.D.

DISPOSITION OF REMAINS

OB IAL 0 CREMATION QHOSPITL DISPOSITION 0 OTHER .

Na., CIty,otonm. Male. r-c)

- OF CEMETERY, CREMATORY OR HOSPITAL MAKING DISPOSAL

17b. r - .

MEDICAL EXAMINER IS FOUND) r

(WHEN UNIDENTIR s

LOCATION (CITY Oft TOWN)

,

NAME OF FUNERALDIRECTOP,. tEAM - ADDRESS 17e.

DATE OF BURIAL OR DISPOSITION SECTION & LOT NO. Of appecable) SIGNATURE OF SEXTON Oft OTHER AUTHORITY FOR DISPOSMO

. . . •

STATE OF VERMONT — AOENCY OF HUMAN SERVICES DEPARTMENT OF HEALTH OFFICE OF THE CHIEF M wig& EXAMINER

MEDICAL EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY

PERMIT NO. 2022c - 0006 Full frinie adecident: -

'Decedents address:

. ,

Date Of death : December 29,2 22 Town of death: St Albans City

Cause of death edified Douai R,. Duck, M.D.

Permission tie-Cremate the bodyOf this decedent at Vermont Crematory East Mompelia, VT

9asbee _

n requested by: Joe FuneralDirector —

Viimont Funirai Oki-dor License Number: 022-01234 —

Being sufficiently informed as to the CatiSeS and circumstances ofthe death of the above described decedent, permission is hereby granted to cremate the body as requested per 18 VSA Sect 5201 (b),

Date; December 29, 2022

Signed: (Via the Vermont Electronic Death Regfotrafion Sotem)

SigiL 47 r Id .r t JIM

Steven L. ShaptrO, MP Chief Medical painter

Office of the Chief Medical Examiner 111 ColchesterAve. , Baird 1 Burlington, VT 05401

This is to. ëerti

el

• late of

• • 'Who *died at .

• at 6;9. •-•••• ',.year• bfake., Was••Q•Eeinate0-at y. N.Orthfiel

On :a.nd cfintainer-iintnker

- The erernatipn burial trAnift medical examiner's ceTtifiCate and a ,signed rcremation • ailthdt*tion. faith .61.1: prerequisite:to. the .ciernatiOn, of said hodyi .aepoinpatiied 'the-same,. • • .

•

JAisposition ,of Cr inains

brato in Charge deiMountan.Crernatory

Cremains Were. • , • scattered, buried etc.

cemeter9.or.ptber lobation

State . signed sexton or person making disposition

This certification may be filed with the Town clerk Th the Town where the disposition look place.

••

US. STANDARD CERTIFICATE OF DEATH LOCAL FILE NO. STATE FILE NO.

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I. DECEDENTS LEGAL NAME (Include AKA's if any) (First, Middle, Last) 2. SEX 3. SOCIAL SECURITY NUMBER

4a. AGE-Last Birthday (Years)

4b, UNDER 1 YEAR 4c. UNDER 1 DAY 5. DATE OF BIRTH (Mo/Day/Yr) B. BIRTHPLACE (City and State or Foreign Country)

Months Days Hours IMinutes

7. RESIDENCE-STATE 7b. COUNTY 7o. CITY OR TOWN

7d. STREET AND NUMBER 7e, APT. NO. 7f. ZIP CODE 7gINSIDE CITY LIMES? 0 Yes o No

8. EVER IN US ARMED FORCES? 13 Yes 0 No

9. MARITAL STATUS AT TIME OF DEATH 0 Married o Married, but separated o Widowed 0 Divorced 0 Never Married 0 Unknown

10. SURVIVING SPOUSE'S NAME (If wife, give name prior to first marriage)

11. FATHER'S NAME (First, Middle, La t) 12. MOTHER'S NAME PRIOR TO FIRST MARRIAGE (First, Middle, Last)

130. INFORMANTS NAME 13b. RELATIONSHIP TO DECEDENT 13c. MAILING ADDRESS (Street and Number, City, State, Zip Code)

14. PLACE OF DEATH (Check only one: see in Motions) IF DEATH OCCURRED IN A HOSPITAL: 0 Inpatient o Emergency Room/Outpatlent 0 Deaden Arrival

IF DEATH OCCURRED SOMEWHERE OTHER o Hospice facility 0 Nursing home/Lang term

THAN A HOSPITAL: care facility o Decedent's home o Other (Specify):

15. FACILITY NAME (If not Institution, give street & number) 16. CITY OR TOWN , STATE, AND ZIP CODE 17. COUNTY OF DEATH

18. METHOD OF DISPOSITION: 0 Burial 0 Cremation 0 Donation o Entombment o Removal from State 0 Other (Specify):

19. PLACE OF DISPOSITION (Name of cemetery, crematory, other place)

20. LOCATION-CITY, TOWN, AND STATE 21. NAME AND COMPLETE ADDRESS OF FUNERAL FACILITY

22. SIGNATURE OF FUNERAL SERVICE LICENSEE OR OTHER AGENT 23. LICENSE NUMBER (Of Licensee)

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ITEMS 24-28 MUST BE COMPLETED BY PERSON WHO PRONOUNCES OR CERTIFIES DEATH

24. DATE PRONOUNCED DEAD (Mo/DayNO 25. TIME PRONOUNCED DEAD

26. SIGNATURE OF PERSON PRONOUNCING DEATH (Only when applicable) 27. LICENSE NUMBER 28. DATE SIGNED (Mo/DayNO

29. ACTUAL OR PRESUMED DATE OF DEATH (Mo/Day/Yr) (Spell Month)

30. ACTUAL OR PRESUMED TIME OF DEATH 31. WAS MEDICAL EXAMINER OR CORONER CONTACTED? o Yes o No

CAUSE OF DEATH (See instructions and examples) 32. PART I. Enter the chain of events-diseases, injuries, or comp) ations-that directly caused the death. DO NOT enter terminal events such as cardiac

Approximate interval:

arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only lines If necessary.

IMMEDIATE CAUSE (Final disease ar condition ----a a

one cause on a line. Add additional Onset to death

resuking in death) Due to (or as a consequence of):

Sequentially list conditions, b. If any, leading to the cause Due to (or ea • consequence of): listed on line a. Enter the UNDERLYING CAUSE c. (disease or injury that Due to (or as a consequence o)): Initiated the events resulting In death) LAST d.

PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given In PART I 33, WAS AN AUTOPSY PERFORMED? 0 Yes 0 No

34. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? 0 Yes 0 No

35 DID TOBACCO USE CONTRIBUTE TO DEATH?

0 Yes 0 Probably

0 No 0 Unknown

36. IF FEMALE 0 Not pregnant within past year

o Pregnant at time of death

0 Not pregnant, but pregnant within 42 days of death

0 Not pregnant, but pregnant 43 days to 1 year before death

0 Unknown if pregnant within the past year

37. MANNER OF DEATH

0 Natural 0 Homicide

17 Accident a Pending Investigation

0 Suicide 13 Could not be determined

38. DATE OF INJURY (Mo/DayNO (Spell Month)

39, TIME OF INJURY 40. PLACE OF INJURY (e.g., Decedent's home; construction site; restaurant, wooded area) 41. INJURY AT WORK? 0 Yes 0 No

42. LOCATION OF INJURY: State: City or Twat

Street & Number Aperlinent No.: Zip Code: 43. DESCRIBE HOW INJURY OCCURRED: 44. IF TRANSPORTATION INJURY, SPECIFY:

ra Driver/Operator O Passenger 0 Pedestrian 0 Other (Specify)

45. CERTIFIER (Check only one): 0 Certifying physlcian-To the best of my knowledge, death occurred due to the cause(s) and manner stated. 0 Pronouncing & Certifying physician-To the best of my knowledge, death =tuned at the time, date, and place, and due to the cause(s) and manner stated. 0 Medical Examiner/Coroner-On the basis of examination, and/or investigation, In my opinion, death occurred at the time, date, and place, and due to the cause(s) and manner stated.

Signature of certifier

46, NAME, ADDRESS, AND ZIP CODE OF PERSON COMPLETING CAUSE OF DEATH (Item 32)

47. TITLE OF CERTIFIER 48. LICENSE NUMBER 49. DATE CERTIFIED (Mo/Day/Yr) 50 OR REGISTRAR ONLY- DATE FILED (lAralay/Yr)

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51. DECEDENTS EDUCATION-Check the box that best describes the highes degree or level of school completed at the time of death.

O 8th grade or less

o 9th - 12th grade; no diploma

52. DECEDENT OF HISPANIC ORIGIN? Check the box that best desc ibes whether the decedent Is Spanish/Hispanic/Latino. Check the No box If decedent Is not Spanish/Hispanic/Latino.

53. DECEDENTS RACE (Check one or more races to indicate what the decedent considered himself or herself to be)

0 White 0 Black or African American . 0 American Indian or Alaska Native

gtmneugtahne enrolled or principal tribe) .

0 High school graduate or GED completed

0 Some college credit, but no degree

0 Associate degree (e.g., AA, AS)

13 Na, not Spanish/Hispanic/Latino

o Yes, Mexican, Mexican American, Chicano

0 Yes, ican Pue rto R

0 Chinese 0 Filipino a Japanese O Korean 0 Vietnamese U Other Asian (Specify)

0 Bachelors degree (e.g., BA, AB, BS)

0 Masters degree (e.g., MA, MS, MEng, MEd, MOW, MBA)

o Yes, Cuban

0 Yes, other Spanish/Hispanic/Latino

0 Native Hawaiian 0 Guamanian or Chamorro 0 Samoan 0 Other Pacific Islander (Specify) (Specify)

0 Other (Specify) O Doctorate (e.g., PhD, EdD) or Professional degree (e.g., MD, DOS, DVM, LLB, JD)

54. DECEDENTS USUAL OCCUPATION (Indicate type of work done during most of working Ile. DO NOT USE RETIRED).

55. KIND OF BUSINESS/INDUSTRY

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VERMONT CERTIFICATE OF DiA701.: Z

Aliases: None

: 1: : •

Date of Death ' •20I6 Time of Death: 5;30 PM Age: 23 Year

Date Of HIM: — Birthplace Burlington, VT . iiat: Male Mother'elParenti*Birth Name Father's/Parents Birth Name: Marital Status Never iit'ri'rriedAr in Civil PnionPpouee/Clvil Union Partner

e Rildelite * ' . „. •

1.1CSPaij1.....0.4011: NO Rape: White Occupation : •,, --,BitsineSsfindustry: Education i no ijet"" • " . '

varlif.U.S. Armed Forces No -.. Veteran of Any War: No

Hospice Care {in kiet 10 flays): ' , Place of Death: ,HOip,itei:'EmerAeriCY:.ToO;n1O4tpatient, The University of Vermont Medical eentei, BurtIngtOri; VT informant : ; circoe, feItIonshIp

.., Other Contrthuting Condition's:

:-:::•:, • . . ... . ... ,. _ ,_ :; . ,_ , , Did Tobacco Use Contribute to pio : pregnant at time or. yew!: Not applicable..

.:bitte Pr.enotMied Dead i:' -- • TIMe.,PionouniOd Deiii;,..30. I'M •-•' • ::, .. . . . . . . .„ . .... . _. , Medical EithitinertontA4d: ''.:' Autopsy Perla:00: ' yo, • • •

Injury,Dateipme: • njury at,WOrki f..; nsn§rtation in d ••.. injuni placo a. injury Lo4tion:

. . -. ,.,.. , , .!* How iniu . bc..0r. e

. ;.:..,. . \

Medical Certifier: Elizabeth A. toodoctrAID; Of4Co:ottlte, Pilaf Medleat ill I t ColchepterAvepOe, Title of Certifier Medical Examiner Date tertifled, December02 20,1..6 'OtIOT Attending 134e1Clen:;;,:11:

.cyntItia NI; Hootey, State Registrar Date Registered: Deeembei ........

-.:. •:: • , ..... „. .,..... ......, ., . . . . . . . , 2. ,...,. _. j. ..

... it Is TO CERTIFY THAT THIS TgA TRUE AND CORRECT. DOPY OF THE INFQKMATION ONIHE.0510!114:. 'CERTIFICATE :ON FILE:N-THE VERMONT DEPARTMENT OF HE/!.1/4I_TH OR OLIST,ODIAt;:AGENCy

A If ' • ' '.' '''' - . ' ... . . . . . . . . . . .. .. . . .

Es. R. commissioner . e0jirkent. of (ffOsilfti

••.• ,.•:•••• • • .• • .. -pis copy not valid unlegs prepared on engraved border displaying state seal o! , .

_ . " • - - • -

•:;.• X

ATE (SEUED:

•••••'="'""'54i.`1'&k:

Name Known to Physician: Date of Death:

DH-PHS-PROD-2012

STATE OF VERMONT DEPARTMENT OF HEALTH

Preliminary Report of Death - Demographic Information Type or Print in Black Ink

, la. DECEDENTS LEGAL NAME (First, Middle, Last, Suffix)

, lb. ALIASES (Any other names the decedent used or was known as) 1c. DECEDENTS LAST NAME AT BIRTH

' 2. SEX: 3. SOCIAL SECURITY NUMBER 4a. AGE-LAST BIRTHDAY 4b. IF UNDER 1 YEAR 4c. IF UNDER 1 DAY

0 Male 0 Female (Years) Months Days Hours Minutes

, 5. DATE OF BIRTH (Month, Day, Year) 6. BIRTHPLACE (City and State or Foreign Country- include Province if Canada)

I 7a. RESIDENCE STREET AND NUMBER (Include Apartment Number) 7b. CITY OR TOWN OF RESIDENCE 7c. STATE OR FOREIGN COUNTRY

8a. EVER IN U.S. ARMED FORCES?

0 Yes 0 No

8b. VETERAN OF ANY WAR?

0 Yes 0 No

Sc. IF SO, WHAT WAR(S)?

, 9. MARITAL STATUS AT TIME OF DEATH: 0 Married 0 Married, but separated

x 0 Civil Union 0 Widowed 0 Divorced 0 Civil Union dissolution 0 1 0 Never Married or in Civil Union 0 Unknown D '

10a. BIRTH NAME OF SURVIVING SPOUSE / CIVIL UNION PARTNER lob. SEX OF SURVIVING SPOUSE/PARTNER

0 Male 0 Female

0 Unknown CO 11. FATHER'S OR PARENTS BIRTH NAME (First, Middle, Last) cr) 4 a

12. MOTHER'S OR PARENTS BIRTH NAME (First, Middle, Last)

z 13a. INFORMANT'S NAME (First, Middle, Last) P C.)

13b. RELATIONSHIP TO DECEDENT

< Z 0 (1)

3c. INFORMANTS MAILING ADDRESS (Street and Number, City or Town, State, Zip Code)

CC w ci.

CC o

CC 0 I- 0 10 CC - 0 -1

14. DECEDENT'S EDUCATION LEVEL: (Check the box that best describes the highest degree or level of school completed at the time of death.)

0 8th grade or less 0 Associate degree (e.g., AA, AS)

0 9th - 12 , grade; no diploma 0 Bachelor's degree (e.g., BA, AB, BS)

0 High school graduate 0 Master's degree or GED completed (e.g., MA, MS, MEng, MEd, MSW, MBA)

0 Some college credit, 0 Doctorate (e.g., PhD, EdD) or but no degree Professional degree (e.g., MD, DDS, DVM, LLB, JD)

IS. DECEDENT OF HISPANIC ORIGIN? (Check the box that best describes whether the decedent is Spanish/Hispanic/Latino. Check the "No"box if decedent is not Spanish/Hispaniclatino.)

0 No, not Spanish/Hispanic/Latino/Latina

0 Yes, Mexican, Mexican American, Chicano/Chicana

0 Yes, Puerto Rican

0 Yes, Cuban

0 Yes, other Spanish/Hispanic/Latino/Latina (Specify) < Lu

IX

Z m U.

>. 03 '0 ai

is. DECEDENTS RACE: (Check one or mom races to indicate what the decedent considered himself or herself to be.)

0 White 0 Asian Indian CI Korean 0 Native Hawaiian

0 Black or African American 0 Chinese 0 Vietnamese 0 Guamanian or Chamorro

0 American Indian or Alaska Native CI Filipino 0 Other Asian (Specify) 0 Samoan

(Name of the enrolled or principal tribe) 0 Japanese 0 Other Pacific Islander (Specify) l,= L. 0 Other (Specify)

13 a) 0 '

17. DECEDENTS USUAL OCCUPATION (Indicate type of work done during most of working life. DO NOT USE RETIRED)

18. KIND OF BUSINESS/INDUSTRY 19. DID DECEDENT RECEIVE HOSPICE CARE? (In past 30 days)

0 Yes 0 No Cl Unknown

0E C..) 0 03

20. PLACE OF DEATH If dead" occurred in a hospital:

(Indicate only one) 0 Inpatient 0 Intensive Care Unit

0 Emergency Room/Outpatient 0 Dead on Arrival

If death occurred somewhere other than a hospital:

0 Nursing Home / Long Term Care Facility 0 Hospice Facility 0 Decedent's Home

0 Other (specify) 0 I-

21a. FACILITY NAME (If not institution, give street and number) 21b. CITY OR TOWN 21c. STATE

22a. METHOD OF DISPOSITION: 0 Temporary Storage 0 Burial 0 Cremation 0 Donation 0 Entombment 0 Removal from State 0 Other (specify)

22b. PLACE OF TEMPORARY STORAGE (Name of cemetery, other place) 22c. LOCATION OF TEMPORARY STORAGE (City or Town, State)

22d. PLACE OF FINAL DISPOSITION (Name of cemetery, crematory, other place) 22e. LOCATION OF FINAL DISPOSITION (City or Town, State)

23a. NAME OF FUNERAL FACILITY OR AUTHORIZED PERSON 23b. ADDRESS OF FUNERAL FACILITY OR AUTHORIZED PERSON (Street and Number, City, State, Zip Code)

24. SIGNATURE OF FUNERAL SERVICE LICENSEE OR AUTHORIZED PERSON 25. VERMONT LICENSE NUMBER 26. DATE OF DISPOSITION (Month, Day, Year)

If attached to a completed Preliminary Report of Death - Medical Certification, this document shall be acceptable for issuance of burial transit and removal permits. This is not a permanent record. A town clerk may not issue certified copies of this record.

Name Known to Physician: Date of Death:

STATE OF VERMONT DEPARTMENT OF HEALTH

Preliminary Report of Death - Medical Certification Type at Pant in Black Ink

19. DID DECEDENT RECEIVE HOSPICE CARE? (In past 30 days) 0 Yes 0 No 0 Unknown

20. PLACE OF DEATH If death occurred in a hospital:

(Indicate only one) 0 Inpatient 0 Intensive Care Unit

0 Emergency Roorn/Outpalient 0 Dead on Arrival

If death occurred somewhere other than a hospital:

0 Nursing Home / Long Term Care Facility 0 Hospice Facility 0 Decedent's Home

0 Other (specify)

21a. FACILITY NAME Of not instftutfon, give street and number) 21b. CITY OR TOWN 21c. STATE

27. MANNER OF DEATH: Note: All deaths that are not Waltzer should be referred toe Medical Examiner. Call 1-888-552-2952.

0 Natural 0 Accident 0 Suicide 0 Homicide 0 Pending Investigation 0 Could Not Be Determined

28. CAUSE PART I. Enter the chain of events - diseases, injuries, or complications -that directly caused the death. DO NOT enter terminal events such as cardiac arrest, respiratory arrest, or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. Enter only one cause on a line. Add additional lines if necessary.

IMMEDIATE CAUSE (Final or condition a.

APPROXIMATE INTERVAL: ONSET TO DEATH

disease --O.- resulting in death.) Due to (or as a consequence of):

Sequentially list conditions, b. If any, leading to the cause Due to (or as a consequence of): listed on line a Enter the UNDERLYING CAUSE (disease or injury that initiated the events resulting c. in death) LAST. Due to (or as a consequence of):

Ec ill 11 d. r.: cc 2.9. CAUSE PART II. Enter other significant conditions contributing to death but not resulting in the underlying cause given in PART I. w 0

< Ei 30. DID TOBACCO USE CONTRIBUTE TO DEATH?

ELI 0 Yes 0 Probably 2 0

0 No 0 Unknown

31. IF FEMALE: 0 Not pregnant within past year 0 Not pregnant, but pregnant 43 days to 1 year before death

Pregnant at time of death 0 Unknown If pregnant within the past year

0 Not pregnant, but pregnant within 42 days of death

it 32a. WAS MEDICAL EXAMINER

1Z) CONTACTED?

0 Yes 0 No

1

32b. M.E. CASE NUMBER 33. WAS AN AUTOPSY PERFORMED?

o Yes 0 No

34. WERE FINDINGS OF AUTOPSY AVAILABLE TO COMPLETE CAUSE OF DEATH?

0 Yes 0 No

, t .11. r 1 ."',7i..f .-7(., r,:,9 ' ''-'' • r'Tf1/77-7.T".7.' t 4L164'1 , . „.,.. •. tl I ED EA A f.16tlICAL EXAMIIIER. CALL 1•6Zil , =

0., 35. DATE OF INJURY 4.) (Month, Day, Year) -a.

36. TIME OF INJURY

El AM 0 PM

37. PLACE OF INJUR i (e.g. Decedent's home, construction site, restaurant, wooded area)

39. INJURY AT :.

0 Yes 0 No

39. LOCATION OF INJURY (Street and Number, City or Town, State)

40. DESCRIBE HOW INJURY OCCURRED

---- -- -

41. IF TRANSPORTATION INJURY, SPECIFY:

0 Driver/Operator 0 Pedestrian

0 Passenger 0 Other (spedfy) - -

42a. ACTUAL OR PRESUMED DATE OF DEATH (Month, Day, Year)

426. ACTUAL OR PRESUMED TIME OF DEATH

0 Am 0 PM

42c. DATE PRONOUNCED DEAD (Month, Day, Year)

42d. TIME PRONOUNCED DEAD

0 AM 0 PM

43a. SIGNATURE OF CERTIFIER -To the best of my knowledge, on the basis of case history, examination, and/or investigation, death occurred at the time, date, and place and due to the cause{s) and manner stated.

43b. DATE CERTIFIED (Month, Day, Year)

43c. NAME OF CERTIFIER (Type or Print) 43cl LICENSE NUMBER

43e. ADDRESS OF CERTIFIER (Street and Number, City or Town, State, rip Code) 44. CONTACT PHONE NUMBER ( )

45. TITLE OF CERTIFIER:0 Physician 0 Pathologist 0 Mecical Examiner

0 Physician Assistant 0 Advanced Practice Registered Nurse

46. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print)

If attached to a completed Preliminary Report of Death - Demographic Information, this document shall be acceptable for issuance of burial transit and removal permits. This is not a permanent record. A town clerk May not issue certified copies of this record.

44, Last Name at girth

0• HUSBAND D 0 SPOUSE (Check one)

4a, Name (First, Mi.ddle, Last)

21.State Of Residence 2b. City or Tocvn of Residence

APPLICANT A HUZ,414Ziaitg micl SPOUSE (Check Ia. NanwtFirstp Middle, Last) I b, LastNanne at Birth I c.Sex

Female ,E1Maie 3. Date of Birth (month, day, Year)

5b.itror Towin of kesiiiefice 6. Date of Birth (rnenth, clay, year) 5a. State of Fiesidence

Alc.Seic

Fe ai j Male, _L

APPLICANT B

VDH-VR-DIN0/2069 C) 9/09 SML

10.1 Certify that this dectee lotearne ibtoltite (final) on (mono', day, year) ,

11:/ :22 / 2016

13. Legal grounds for decree (itlefifir)

Pattie S have lived t Operate in excess Of 6 consecutive months

IL Typqa decree (check one) PlYorce AntiOlment

14. Cciurt nagets Name

12, county of decree

FRANKLIN

IS. Date Signed (Month, day, year)

DEPARTMENT OF HEALTH VERMONT RECORD OF DIVORCE OR ANNULMENT

45-2-16 Frdm Dept Of Health Use ONLY

Do-ckt # State File #

MARRIAGE 7a. State 614keign Country ttif thig rriattiage

Vetrnoht

7b. City-or Town of this Marriage .

St Albans

7c. Dated this rriarti'age (rtiontlktlay, y,-,a)_1

Ela, Pate c °We last resided in same household ' (triorith, day, year)

gb. Nliittilier )M Children Under 18 in this-neusehdd as of the date in item Ba.

NONE 9a.,nramq Of perrtinner's (Netorney 9b. Attorney's Address (street, 1 itin..yri, state, up)

MHO ATTORNgY

RV)

• ••;:laK,Tamite,W,,W.:51,

'A'," • 7:1,

-; :DEPARTMENT OF 11E1q4". 171

VERMONT RECORD PP DIVPRC C)RANNULMENT • , .

ReOth UsicONLY . . _ . • . . f..1; ...... DOck6i I _

. • • • State File ft

Cl.tA

SCX

•

„.••

F ernal0 Mafe

3. Date of Birth (month, day, year)

-

..Last.Narriii4t Birt

12. County of &wet

j.

b1-1-VR-DIV,4)2:609 : •

IS 18 TO CEItiFY THAT THIS IS A TRUE AND coRkEof bo0,? OF THE iNFOkiviATfON ON THE ORIGINAL (/ . , -

. . . . . :

•

hibv. 'bERTIFICATE-ON F1LE:fN THE VERMONT DEPARTMENT OF HEALTH 014 OUST() 1A, L._ A. GENc • , • :::!! :

0 • '

; AN:2:3 2017

••••"-' 4•;Z

ATTEST •• • Commissioner '\ • " t ;4

• VOrMOMV0y011inont of Heall4,

f

„This copy not valid unless prepared on engraved bRrder displayinf) afa.ta 8141# VAirOgrAl? :

..RA Sti - '

DH-PHS-MARAPP-2012

VERMONT DEPARTMENT OF HEALTH APPLICATION FOR VERMONT LICENSE OF CIVIL MARRIAGE

FEE FOR CIVIL MARRIAGE LICENSE $45.00

APPLICANT A • BRIDE EGROOM ESPOUSE (check one Ia. LEGAL NAME (First, Middle, Last) lb. LAST NAME AT Itin-L (Maiden Surname)

2. SEX 3. DATE OF BIRTH (Month, Day, Year) 4. BIRTHPLACE (State or Foreign Country)

ba. RESIDENCE ADDRESS Number and Street) 5b. CITY OR TOWN OF RESIDENCE

Sc. STATE OF RESIDENCE 5d. COUNTRY OF RESIDENCE

6a. FATHER'S OR PARENT'S NAME (First, Middle, Last Name at Birth) Ob. BIRTHPLACE (State or Foreign Country)

7a, MOTHER'S OR PARENT'S NAME (First, Middle, Last Name at Birth) 7b. BIRTHPLACE (State or Foreign Country)

APPLICANT B LJBRIDE ['GROOM ESPOUSE (check one) 8a. LEGAL NAME (First, Middle, Last) 8b. LAST NAME AT BIRTii (Maiden Surname)

9. SEX 10. DATE OF BIRTH (Month, Day, Year) 11. BIRTHPLACE (State or Foreign Country)

12a. RESIDENCE ADDRESS (Number and Street) 12b. CITY OR TOWN OF RESIDENCE

12c. STATE OF RESIDENCE 12d. COUNTRY OF RESIDENCE

13a. FATHER'S OR PARENT'S NAME (First, Middle, Last Name at Birth) 13b. BIRTHPLACE (State or Foreign Country)

14a. MOTHER'S OR PARENT'S NAME (First, Middle, Last Name at Birth) 14b. BIRTHPLACE (State or Foreign Country)

THE CONFIDENTIAL INFORMATION BELOW MUST BE COMPLETED. IT WILL NOT APPEAR ON CERTIFIED COPIES OF THE RECORD.

APPLICANT A 22. TOTAL NO. OF MARRIAGES AND CIVIL

UNIONS, INCLUDING Tuts ONE 23a. LAST MARRIAGE OR CIVIL UNION EN" FL BY (check one)

Death Divorce Dissolution Annulment Civil union did not end; m3rry Fg civil union nartner

23b. DATE LAST MARRIAGE OR CIVIL UNION ENDED

Month Year

APPLICANT B 25. TOTAL NO. OF MARRIAGES AND CIVIL 26a. LAST MARRIAGE OR CIVIL UNION ENDED BY (check one)

UNIONS, INCLUDING THIS ONE Death Divorce Dissolution Annulment Civil union did not end;

marrying civil union partner

26b. DATE LAST MARRIAGE OR CIVIL UNION ENDED

Month Year

DOES EITHER APPLICANT HAVE A LEGAL GUARDIAN? YES NO 18 V.S.A. § 5131 (4)(A) provides that "parties to a civil union certified In Vermont may elect to dissolve their civil union upon marrying one another but are not required to do so to form a civil marriage." The option to elect dissolution of the civil union Is found in the confidential section of the marriage license and shall become effective upon solemnization of the marriage. APPLICANTS

We/I hereby certify that the information provided is correct to the best of our/my knowledge and belief and that we are free to many under the laws of Vermont. 15a. SIGNATURE (Applicant A) 16b. DATE SIGNED 16a. SIGNATURE (Applicant B) 16b. DATE SIGNED

16c. TELEPHONE NUMBER 16d. E-MAIL ADDRESS 16c. TELEPHONE NUMBER 16d. E-MAIL ADDRESS

Planned marriage date Location (City or Town)

Officlant name and mailing address

Your mailing address after wedding

Do you want a certified copy of your Civil Marriage Certificate ($10.00) Yes No

Date license issued Clerk issuing license

THIS WORKSHEET MAY BE DESTROYED AFTER CIVIL MARRIAGE IS REGISTERED

DH-PHS-MARUC-2D12

201600012 LOCAL FILE NUMBER

DEPARTMENT OF HEALTH VERMONT LICENSE AND CERTIFICATE OF CIVIL MARRIAGE

BRIDE lk GRoom TSPOJSE STATE FILF NUMRPR

IL LEGAL NAME (Fiat, Middle, Last) to. LAST'. " '' z AT HIRT-. Newer, seaman,

2. lex J. DATED? BIRTH (Month, Day, Year) 4. BIRTHPLACE (Stale or Foreign Country)

Se RESIDENCE ADDRESS (Sumber end Street) 1 _ _

15b. CITY OR TOWN OF RESIDENCE

Sc. STATE OF RESIDENCE Ed. COUNTRY OF RESIDENCE

Se FATHERS OR PARENTS NAME OM Middle, Last Name at BEM) r

_ 6b. BIRTHPLACE (State or Foreign Country)

la. MOTHERS OR PARENTS NAME (first, Middle, Last Name at Birth)

I

7b. BIRTHPLACE (State or Foreign Country)

*APPLIC NT B - -x-1 p. R 'IDE .G.ROOM SPOUSE , , _1 ILLEGAL NAME (F .-st I U) ab. LAST NAME AT La.., (Minden Orsmalran

9. SEX 10. DATE OF BIRTH (Month, Day, Year) -

11. BIRTHPLACE (Stale or Foreign Courrby)

120. RESIDENCE ADDRESS (Number end Street)

12o.STATE OP RESIDENCE

12b. CITY OR TOWN OF RESIDENCE

. • -

12d. COUNTRY OF RESIDENCE

-FATHERS 13a. OR PARENTS NAME first, Middle, Last Name at Birth)

,,...

I 130. BIRTHPLACE (Slate or Foreign Country)

14a. MOTHER'S OR PARENTS NAME (First, Paddle, Last Name at Birth) 1 14b. BIRTHPLACE (State or Foreign County)

Weil hereby certify that the Information provided is correct to the best of our/my knowledge and belief and tiptre are free toparry under the laws of Vermont. 111a. SIONAN (fi -Al, RE opargot

. -

DATE tab. DA SIGNED 1 Pia-SIGNATURE (APPIlcard la)‘ I i '

I lats. DATE SIGNED

- CERTIFIC ION I hereby certify meat the above, named parsorsave

cm -, rr. • + . fads Meted In the loratroing declaration of intentkin of marriage and compiled Milt the (=doge laws of the State of Vermont.

' 0 GIANT (See Instructions on back)

This kens* RUSIOTIZOR the mintage IN VERMONT ONLY of the above named partials by any person duty authorized to perform a montage-

17a. DATE ON WHICH LICENSE WAS ISSUED (Month, Day, Yee*

March 3, 2 151. I CERTIFY THAT THE ABOVE PERSONS WERE MAR .RIE9.611,_ (1,4011. Dey, Year)

Tab. WHERE MARRIED - CITY OR TOWN

L..

:

00,

tiri(li I) 18c. 3

A ONA OF PERSO C , . EREMONY _... . ......._ _

tad- Ts rLE4€

C. T• RCM(

Town of Bennington ii.. RWE CYPONIcS

-

161. TELEPHONE NUMBER

17d. THIS UCENSE 13 VALID FROM March 3, 2016 TO 1 Ig. MAILING ADDRESS OF PERSON PERFORMING CEREMONY (Nurnber and Street, Cay or Town, State,2Ip Code)

May 2, 2016 DATE

REGISTRATION 19. CI, KZ SIGNATURE

..i e Jiff ' - A II AL i 1st. DATE RECEIVED BY LOCAL REGISTRAR

March 1, 7016 a. 'US Co - (Clerk's Signature)

ATTEST:

20E. TOWN

Town of Bennington 20e DATE