Spicer, Aimee 4 IYIAIKTLAIVU JIM t Utf H ti iviCIV I Ur T1CHL1 lI
DIVISION OF STATISTICAL RESEARCH AND RECORDS, 301 W. PRESTON STREET, BALTIMORE 1, MARYLAND
BURIAL BURIAL-TRANSIT PERMIT This permit must accompany remains to destination
TRANSIT 1. PLACE OF DEATH 2. USUAL RESIDENCE (Where deceased lived, If institution: Residence before admission)
PERMIT a.COUNTY Mart ),:e ry a. STATE liartliaancl b.COUNTY k.tontr otney J MARYLAND
b.CITY OR TOWN(if outside corporate limits, c.LENGTH OF STAY IN lb c.CITY OR TOWN(If outside corporate limits,write RURAL and give nearest town)
CD .0 `o write RURAL and give nearest town)
a) 76ethesda Years .,ethescla
x c a d.NAME OF HOSPITAL OR INSTITUTION(if not in hospital,give street address) d.STREET ADDRESS e. IS RESIDENCE
a) ARM?
cu 4405' East <�est Hi_. way 4405 E' t West di hway YES❑ FNO 1
0 o 3 DECEASED NAME OF First Middle Last 4. ODATE rF Month ��"pay Year
s .y .... (Type or print) i-a .a f'a)`.r. „1. :-,P ZC! A DEATH cF / 1 194'`
3 o 5. SEX 6.COLOR OR RACE '7. MARRIED❑ NEVER MARRIED❑ 8. DATE OF BIRTH 9. AGE(In years IFUNDER1YEAR IFUNDER24HRS.
T o y }� _ I22��t birthday) Months Days Hours I Min.
-o - cv ea � '"h te. WIDOWED t_1 DIVORCED❑ fi .3„ 1<379 8+€f� yrs.
0
_aaa)) 10a.USUAL OCCUPATION(Give kind of work done 10b.KIND OF BUSINESS OR 11.BIRTHPLACE(County&State,or foreign country) 12. CITIZEN OF WHAT
m during most of working life,even if retired) INDUSTRY COUNTRY? I: ,
-o .+' a suse''i `e i`ceW York • } •
to 'a 13. FATHER'S NAME 14. MOTHER'S MAIDEN NAME
O U �$ p�p�yg a�j.,{t Aimee
c.N . O (.71Toro. • iyatt Aime
o ma) 15.WASDECEASEDEVERINU.S.ARMEDFORCES? 16.SOCIALSECURITYNO. 17. INFORMANT Address
h �'o (Yes,no,or unkown) (If yes give war or dates of service) _ L.
1 ' -Ttl ,t
O . 219-$4.8441 Frances L. A-!art Same as Item 2.
N
y AUTHORITY FOR BURIAL, TRANSPORTATION, REMOVAL, CREMATION OR OTHER DISPOSITION
H .N ° This burial-transit permit,when completely filled in and bearing below the signatures of the attending physician and funeral director,
o. '=;� constitutes authority for burial, transportation, removal, cremation or other disposition of the deceased named above.
O
CEMETERY OR CREMATORY AUTHORITY SHALL FILL OUT SECTION BELOW
0� The deceased named above was buried ❑ cremated ❑ in the cemetery or crematory named in Item 23c. Burial was in
Section 35 Lot. /%5 Grave I made the ap ropriate entry i he cemete or crematory register.
o d Signature 7.<<,. C e-, 7.L L({/
�.:= Sexton or other person in charge
U O This burial-transit permit must be signed above by the cemetery or crematory authority. Where there is no full-time person in
`°`;= charge of the cemetery, the funeral director may sign as sexton.
oIf burial took place in Maryland, this permit must be returned within ten days to the Division of Statistical Research and Records,
c. Maryland State Department of Health,301 W. Preston Street, Baltimore 1, Maryland.
E Z ,_
(13
o •21. I certify that (I) (this hospital) attended the decease from , l ' to , 19 , that (I) (we) last
.€:•_-_-: la d saw the deceased alive on 19' / , and that death occurred 4_ Ili, from the causes and on the date stated above.
~L 22a. SIGNATURE
3 L 22b,. DATE SIGNED
`"n Z a`:(n r (t' ATTENDING rt MED. STAFF z
a.).,.- 2 -2 M.D. PHYS. DIRECTOR ❑ PHYS. ❑
1- , a 0 22c. PHYSICIAN'S
Lj` n• 72d. ADDRESS cx ".i
` c .c NAME(Type) it i I L _ ti, I 1 (<E�{' r r�,' j Uq f:
ci9
z•= Z E 23a. BURIAL,CREMATION, 23b. DATE THEREOF 23c. NAME OF CEMETERY OR CREMATORY 23d. LOCATION(City,town or count (St )
a o „) REMQVAL(Specify) Glen ;ally New -York
" "" burial .5.25.67 Pine View Cemeteryt
24. FUNERAL DIRECTOR ADDRESS
In using this permit the funeral director certifies that he
VR AIS (4) ER i A. UMPH . f Beth s Maryland has previously filed a certificate of the death of this
20M 1/65 decedent.