Dunn, Mary/ - lstxtTIMOKFfi I Y HEALTH DEPARTMENT
BURIAL BURIAL-TRANSIT PERMIT This permit must accompany remains to destination.
TRANSIT I,HAME OF DECEASED 2.DATE AND HOUR OF DEATH
PERMIT Tvoe or Print) .-#`a`hi'k : tint. 7.1-
3. PLACE OF DEATH IN BALTIMORE, MARYLAND - 4. USUAL RESIDENCE (Where deceased lived. If institution: residence before admit
_ _t W A.STATE B. COUNTY
m g.y
i— tt•Jet 3.`�.,jai
FULL NAME OF (If not in hospital or institution, give street
3 0 J HOSPITAL OR address or location) C. CITY OR tQWN outsi a ci limits, write RURAL and give township)
} 0 4:( INSTITUTION
4s
O W I Public: k .-a.-. mice j 1 D. STREET ADDRESS (If rural, give location)
03 F=- N $S 4,14. 40 ".k:0+1°' �!'B :1 t tree'- s3 r..s7`sty�t.
Q• Z Q
w W U 5. SEX 6.RACE 7. MARRIED, NEVER MARRIED 8.DATE OF BIRTH 9. AGE (In years If Under 1 Yr. If Under 24
0 = ce WIDOWED, DIVORCED(specify) !� t last birthday) Months: Days Hours Mi
a 3 W yrl �� 72
'.......i W Z F- IOA.USUAL OCCUPATION(Give kind of work 10B.KIND OF BUSINESS OR INDUSTRY 11. BIRTHPLACE(State or foreign country) 12.CITIZEN OF
C. O Q done during most of working life,even if retired) WHAT COUNTRY?
LU f-4( la ALAN Jett %.`.. W.
r^ Z I 13.FATHER'S NAME 14. MOTHER'S MAIDEN NAME�y�,
NO f- F- yy r Josephinetic
W ce d I s.,'i.l--
0 2,-,
0 15.Was Deceased Ever in U. S. Armed Forces? 1 6.SOCIAL 17.INFORMANT ADDRESS
O J Y' (Yes,no or unknown)(If yes, give war or dates of service) SECURITY NO.
= Z o 1_63, t r0724 Rze0"i >+ ET A, Nato, Ty. .
_ m
z AUTHORITY FOR BURIAL, TRANSPORTATION, REMOVAL, CREMATION OR OTHER DISPOSITION
O w
w
vi
F- This burial-transit permit when completely filled in and bearing below the signatures of the attending physician and funeral direc
ix
d O O O constitutes authority for burial, transportation, removal, cremation or other disposition of the deceased named above.
F- z o CEMETERY OR CREMAT RY AUTHORITY SHALL FILL OUT SECTION BELOW
z >- z
Q OO ~ O The deceased named above was buried cremated in the cemetery or crematory named in Item 24C. Burial was
Z ra Z W — ---
a.
0w O a Section r- Lot r 3' Grave 1 . I have made the appropriate entry in�cemetery or crematory register.
V �/^^ �
0 F- I- vV) ti1LQ�to � W
h Mat,
0
N w w Signature
fl F. Z v, ce Sexton or other person in charge
Q O
OCL
c U W
j d 00 = 0 THIS BURIAL-TRANSIT PERMIT MUST BE SIGNED ABOVE BY THE CEMETERY OR CREMATORY AUTHORIT`
r ._ U I- w WHERE THERE IS NO FULL-TIME PERSON IN CHARGE OF THE CEMETERY, THE FUNERAL DIRECTOR MAY SIGI
J Z
La AS SEXTON.
W 01
N
Q Q f-
W ce
ce Z
a I.- a > IF FINAL DISPOSITION TOOK PLACE IN MARYLAND, THIS PERMIT MUST BE RETURNED WITHIN TEN (10
_ U W DAYS TO THE BUREAU OF VITAL RECORDS, BALTIMORE CITY HEALTH DEPARTMENT, MUNICIPAL OFFIC
Q Q �
w z ce o a BUILDING,BALTIMORE, MARYLAND 21202.
`^ m a f O
O 0 r_n O I— 22. I certify that (I)(this hospital) attended the deceased from ste 18 19 . to - - 19
`/ W = U `h that (I)(we) last saw the deceased alive on as II fir („ ( ) p
H I- r Q --= 19 ;3S} and that rn our opinion death occurred on the d
QU Z co and hour and,from the causes stated abover.( (We) (did)(di, /view the body after death.
J W O 0 F- 23A.SIGNATURE 23B.DATE SIGNED
X W U
W W ~ a- O - .., ' ' M.D. AttendingMed. Staff +)r f.
_ d tom.•' __ ,~� Phys. ❑ Direcbr❑ Phy s. '%� f
I-
J a' = H 23C.PHYSI CIAMS 23D.ADDRESS
U O O ,A Z NAME (Type) Y
Z 0 - w O Y. '. e. -..fr - ,e_! M.D. I' t"TI.t1. 7 s "t,+lt,.•:
Z F- Z o V 24A. BURIAL CREMATION, 24B. DATE 124C.NAME of CEMETERY or CREMATORY 24D. LOCATION 6(City,ytown, or county) (State)
4 0 0 0 O
Q O re I- v) REMOVAL ISpecifyl
' .fie ` ,:..., - _
25A.DATE REC'D BY HEALTH DEFT. 1256.NAME OF REGISTRAR 12',C. FUNERAL DIRECTOR ADDRESS
e
__L_ r
,..-. .
VS 150-REV. 1/1/65 IN 151N6 THIS MUD* Ttt G1t mo[rrro nror�r,r.^"'- ..•- ------ --
-_ —
is:Ai
_
r -
' ='°
t
'x:x