Abbott, James 4 twig Vr EIIRRILMEI U
3 DEPARTMENT OF HEALTH AND MENTAL HYGIENE
BURIAL , BURIAL-TRANSIT-PERMIT This permit must accompany remains to destination
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1.DECEASED NAME , f..FIRST MIDDLE `pf 1�j LAST/g 2o.DATE OF
OF DEATH MONTH
DAY YEAR{�� 1b.{HOUR
TRANSIT
ERMIT (TYPE OR PRINT) °R I L iit LL L/ 0/ ttB, j5 Y?I / '.- M
3.SEX 4.RACE S.DATE OF BIRTH 6.AGE (IN YEARS LAST BIRTHDAY) IF UNDER I YEAR IF UNDER 2A HRS.
M DAY.. YEAR ....... MONTHS DAYS HOURS MIN.
{�L�r I // f T" j f / / r //,,
w o { �C,..y J � C,� /irf I 1�- � !.S YRS.
` E v° 7a.BIRTHPLACE (STATE OR FOREIGN 7b.CITIZEN OF WHAT.COUNTRY? 8. -
9:BALTIMORE CITY OR COUNTY OF DEATH
mrr o O C 13 �O�(UjjNTRYI44. ` Jf / y",�, MARRIED NEVER MARRIED ❑ �7 y/ '' f L J� "T'
. /Y /�T/ Sl''"'Dl 4'i s ✓ r , WIDOWED DIVORCED ❑ j/"7 / /J�' Y "�~ i,.• l`'/ f MD.
-o - o r10.CITY OR TOWN O,F DEATH /// 11. NAME OF HOSPITAL,NURSING HOME OR OTHER INSTITUTION 12e.USUAL OCCUPATION 12h.KIND OF BUS ESS OR
O O a N �` =. (IF NOT IN AIL FACILITY, IVE 51hEET ADDRESS( (TYPPWpF WORK F RMO T OF W RKING LIFE) INDUSTRY
04 a" /�f/1 / 2 /I-/j'.h£ % ,1' //'firs iI t> Z E.c ti « ,
74 o r s 1 l�' L-- l G t li'rr, :r
ca - .2 u USUAL RESIDENCE(IF NURSING HOME OR OTHER INSTITUTION,GIVE RESIDENCE BEFORE ADMISSION)
Z T o a 130.STATT}E1j I13b COUN Y) y' 13L.CIT.Y�OR TOWN• 13d.INSIDE CITY LIMITS? 13e./ST/Y,E T ADDRESS / r
it o -.N ! J 2, I , .;' 1 f C. I i,,f -.)14/LI.G. YES❑ NO I / / 4//[f.b4.-4, re 1jP�.,F, -.G-
R -D o
14.FATHER'S NAME 15.MOTHER'S MAIDEN NAME
a -0 u FIRST MIDDLE LAST FIRST _ p LAST '
a _ :rtr' , ., %, 1 / T ,/,--/ZID> - / 7L C/•41/1�-/41
O d o 16a.WAS DECEASED EVER IN U.S.ARMED FORCES? 16b.SOCIAL SECURITY NO. 17.INFORMANT ADDRESS
p ° (YES, N NOWN � - ,t'J 3 a ( yes
) (IF YES,GIV��Ef�W�)AR OR DATES)
ram_/ �[!� /+�v" ,4 J� J�J /
Q o 'v y,�s I 1" 8 , �.e-1 /5 f'-J, -4 /4/ .). f+1,)� ;'7Y ' "d e' i" % j `" F111 dit,'
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W o N AUTHORITY FOR BURIAL,TRANSPORTATION,REMOVAL,CREMATION OR OTHER DISPOSITION
1 3 v o This burial-transit permit,when completely filled in and bearing below the signatures of the attending physician and funeral director,constitutes
N authority for burial,transportation,removal,cremation or other disposition of the deceased named above.
Z ° o o CEMETERY OR CREMATORY AUTHORITY SHALL FILL OUT SECTION BELOW ----`c/
Oa `-- The deceased named above was buried vl cremated in the cemetery or crematory named in Item 23c.Burial was in Section
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a. a
• o N, .Lor /i / Grave .I have made t e appropriatepr entry in the cemetery or crematory register
cn v \ L j
o � v /i
co - Signature - 1 Date Signed:
r^ » o ° Z Sexton or other person in charge v
Oo. a�' P This burial-transit permit must be signed above by the c metery or crematory authority.Where there is no full-time person in charge of the
a a cemetery,the funeral director may sign os sexton.
ex o A, If burial took place in Maryland,this.Rermit must b red within,,days to the State Dept.of-Health and Mental Hygiene --
74 o N o F' Division of Vital Records,
A- o. E m V 301 W.Preston Street,
> o IBaltimore,Maryland 21201.
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O £ r a W
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c ° EOY l _
FL a r 220.1 certify that-(Jy(this hospital)attended_the deceased from `" , 19 r ,to , 19 - ,that_(4),(we)last
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saw the deceased alive on 19 r ,and that in(my)(our)opinion death occurred on the dote and hour and from the causes stated
Z O« above,(J)(we)(didi`(did not) w.-tInbod after deat�y,
Z=N 21b.SIGNATURE ) y i /r DEGREE 12t.DATE SIGNED
°C °Z.H 'n' _ s `. � .Y' } ATTENDING MEDICAL STAFF
4 F•
o `� -'�'` '' r-"--" „�^^- -`f PHYSICIAN ❑'DIRECTOR PHYSICIAN 0
22d.PHYSICIAN'S NAME(TYPE OR,PRINTI hj / 12e.ADDRESS
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13a.BURIAL,CREMATION,REMOVAL` .236.DATE 23L.NAME .F CEMETERY OR MATORY 23d.LOCATION
(SP )pi ,,I ,? / f )} -•+. j,{ • C�'R{TOWN �� BOUNTY STATE
1?IJ �X - Xb"LJ;f /J 1 y It'e• v(C/d.,,.r' (9/.. l c T F ° .J d l l,I �e:� -r,f1Lt. /"/f i
24.FUNERAL D RECTOR `/
DHMH-16 60M 7/73 NAME I Ap6RE55 I using this permit the funeral director certifies that he
vR A is a �A �� / `/ ��-s- 1 has reviousl filed a certificate of the death of this
( 1 )) : _A,41/ # 1 .�,L -" 6. Lsl,' y2; t-, '' 1.ff I decedent. y