Washburne, Ruth M V'QH-HSI-BTP-2023 RMONT DEPARTMENT OF HEALTH Permit No. Z 1 Z
BURIAL-TRANSIT PERMIT
Permit for Removal, Disinterment and Reinterment
1. Decedent's Name 2.Sex 3. Date of Death
Ruth M.Washburne Female March 06,2023
4.City/Town of Death 5. Date of Birth 6. Place of Birth
Rutland City March 3 , 1931 Granville,NY
7. Name and Address of Funeral Director
rill)
Christopher J.Book,Mason Funeral Home,P.O.Box 277 Fort Ann,NY 12827
PERMISION REQUESTED FOR:(Check only one box and complete the appropriate section)
0 Temporary Storage or Donation(Section A) Cremation or NOR(Section C) 0 Burial or Entombment(Section D)
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
(004)
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
i
Signature of Sexton/ emetery Official or Representative of Organization Receiving Donation Date
SECTION B: IF REMOVAL FROM TEMPORARY STORAGE/PLACE OF DONATION OR DISINTERMENT
Name of Cemetdf. /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 NATUR a IC 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
(01011)SECTION D: IF BURIAL OR ENTOMBMENT IN VERMONT
Name of Cemetery City/Town Date
k
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 1Date
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 Crematory Queensbury,NY March 07,2023
PERMISSION GIVEN TO DISPOSE OF SAID BODY S STATED ABOVE(Title 18,V.S.A.5201)
Signat,r "deputy or neral ctor ICity/To l ! / 1Date
is permit is t filed with the City/Town Clerk by the 10th day of the month following disposition.(Title 18 V.S.A.5215)
- VDH-HSI-BTP-2023 LF 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
Ruth M.Washburne Female March 06,2023
4.City/Town of Death 5. Date of Birth 6. Place of Birth
Rutland City March 3 , 1931 Granville,NY
7.Name and Address of Funeral Director
Christopher J.Book,Mason Funeral Home,P. O.Box 277 Fort Ann,NY 12827
PERMISSION REQUESTED FOR:(Check only one box and complete the appropriate section)
El Temporary Storage or Donation(Section A) ❑ 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 1City/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 1City/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 Crematory Queensbury,NY March 07,2023
PERMISSION GIVEN TO DISPOSE OF SAID BODY S STATED ABOVE(Title 18,V.S.A.5201)
Signal 6 4'deputy or neral ctor City/ToAl /J !Date
his permit is t 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
4.
-� MEDICAL EXAMINER'S PERMIT TO CREMATE OR PROCESS BY NATURAL
ORGANIC REDUCTION A DEAD HUMAN BODY
PERMIT NO. 2023c- 0980
Full name of decedent: Ruth M. Washburne
Decedent's address:
2665 County Rt 17
Granville, NY
Date of death: March 06, 2023 Town of death: Rutland City
Cause of death certified by: Andrew Philip DeNicco
Permission to cremate or process by natural organic reduction the body of this decedent at:
Pine View Crematory
Queensbury, NY
Has been requested by: Christopher J. Book
Vermont Funeral Director License Number: 022-0001143
Being sufficiently informed as to the causes and circumstances of the death of the above described
decedent, permission is hereby granted to cremate or process by natural organic reduction the body
as requested per 18 V.S.A. Section 5201.
Date: March 06, 2023
Signed: (Via the Vermont Electronic Death Registration System)
Elizabeth A. Bundock, MD
Chief Medical Examiner
Office of the Chief Medical Examiner
111 Colchester Ave., Baird 1
Burlington, VT 05401
VDH-OCME-DP-01/2023
r k.-
Public Health Law Sec. 4145(2b)
Receipt
Human remains of delivered on , 20
Pine View Cemetery Representing the funeral home names oil lat permit
Official Funeral Directors Reg.or License#