Buell, Shirley fZ
VDH-PHS-BTP-2011 VERMONT DEPARTMENT OF HEALTH Permit No. 2 O
IAL-TRAN PERMIT
Permit fo Removal, Disinter nt and Reinterment
1. Decedent's Name 2. Sex 3. Date of Death
Shirley Ann Buell N Female March 27, 2017
4.City/Town of Death 5. Dab of Birth 6. Place of Birth
Burlington February 17, 1938 Ticonderoga,NY
• 7. Name and Address of Funeral Director
Wilcox& Regan Funeral Home, 11 Algonkin St., Ticonderoga,NY 12883
PERMISSION REQUESTED FOR: (Check only one box and complete the appropriate section)
❑Temporary Storage 6t'don,ation(Section A) 0 Cremation(Section C) ❑Burial or Entombment(Section D)
0 Removal From Temporary Storage/Place of Donation or Disinterment(Section B) 2.Removal From State(Section E)
SECTION A: IF TEMPORARY STORAGE OR DONATION IN VERMONT
Name of Cemetery/Place or Donation Facility City/Town Date
O 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 ICity/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
SECTION D: IF BURIAL OR ENTOMBMENT IN VERMONT
41, 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: 0 Buried 0 Entombed Date
4110 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 Crematory Queensbury,NY March 28, 2017
PERMISSION GIVEN TO DISP OF SAID BODY AS STATED ABOVE(Title 18,V.S.A. 5201)1S .ture of Cler ep or Funer Djtaef City/Town Date
I *" ,,ge.1xLiA/c r " 3-2r /7
,.. This permi is to e filed with the City/Town Clerk by the 10th day of the month following disposition.(Title 18 V.S.A.5215)
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STATE OF VERMONT-AGENCY OF HUMAN SERVICES- DEPARTMENT OF HEALTH
OFFICE OF THE CHIEF MEDICAL EXAMINER
MEDICAL EXAMINER'S PERMIT TO CREMATE A DEAD HUMAN BODY
PERMIT NO. 2017c - 1080
Full name of decedent: Shirley Ann Buell
Decedent's address:
2553 NYS Route 9N
Crown Point,NY
Date of death: March 27, 2017 Town of death: Burlington
Cause of death certified by: Mark Sabra
Permission to cremate the body of this decedent at:
Pine View Crematory
Queensbury,NY
Has been requested by: James A. Meunier
Vermont Funeral Director License Number: 022-0000010
Being sufficiently informed as to the causes and circumstances of the death of the above described
decedent, permission is hereby granted to cremate the body as requested per 18 VSA Sect. 5201 (b).
Date: March 28, 2017 ,
Signed: (Via the Vermont Electronic Death Registration System)
Steven L. Shapiro, MD
Chief Medical Examiner
Office of the Chief Medical Examiner
111 Colchester Ave., Baird 1
Burlington, VT 05401
VDH-OCME-CP-01/2011