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Southard, Mary 3IAIt UI MIRKILIMU 3 DEPARTMENT OF HEALTH AND MENTAL HYGIENE BURIAL BURIAL-TRANSIT PERMIT This permit must accompany remains to destination 1.DECEASED NAME FIRST - MIDDLE LAST 2o.DATE OF DEATH MONTH DAY YEAR Th.HOUR TRANSIT (TYPE OR PRINT) PERMIT MARY F. • SOUTHARD 1 28 79 12:40P 3.SEX 4.RACE 5.DATE OF BIRTH 6.AGE (IN YEARS LAST BIRTHDAY) IF UNDER 1 YEAR IF UNDER 24 HRS. ~ MOt1TH .DAY YEAR.,-" MONTHS DAYS HOURS MIN. v , 2:}. t 1 I YRS. ` E o 7a.BIRTHPLACE ,STATE OR FOREIGN lb.CITIZEN OF WHAT COUNTRY? 8. , 9.BALTIMORE CITY OR COUNTY OF DEATH Ti O COUNTRY) MARRIED+❑ NEVER MARRIED ❑ p { COUNTY >-° j�..'. - L f . WIDOWED DIVORCED ❑ SALT/M©RE MD. a -' v o -10.CITY OR TOWN OF DEATH 11. NAME OF HOSPITAL,NURSING HOME OR OTHER INSTITUTION 120.USUAL OCCUPATION 12b.KIND OF BUSINESS OR N a o S (IF NOT IN SUCH FACILITY,GIVE STREET ADDRESS) (TYPE OF WOJtKTOR MOST OF WORKING LIFE) INDUSTRY N s r o TOWSON GREATER BALTIMORE MEDICAL CENTER (:1 .- USUAL RESIDENCE(IF NURSING HOME OR OTHER INSTITUTION,GIVE RESIDENCE BEFORE ADMISSION) Z 3 0 0 13o.STATE 1136 COUNTY I13L)CITY OR TOWN I3d.INSIDE CITY LIMITS? 13e.STREET ADDRESS 'a YES NO O T N Q . o`c 14.FATHER'S NAME 15.MOTHER'S MAIDEN NAME 1 a .0 T FIRST MIDDLE LAST FIRST MIDDLE LAST W K O a O "6d Q 16o.WAS DECEASED EVER IN U.S.ARMED FORCES?-'16b.SOCIAL SECURITY NO. 17.INFORMANT ADDRESS J• N 3 O (YES,NO OR UNKNOWN) (IF YES,GIVE WAR OR DATES) Q a C-O - m a O I- ° ° W O _i:-, AUTHORITY FOR BURIAL,TRANSPORTATION,REMOVAL,CREMATION OR OTHER DISPOSITION Le3 Li o This burial-transit permit,when completely filled in and bearing below the signatures of the attending physician and funeral director,constitutes in authority for burial,transportation,removal,cremation or other disposition of the deceased named above. Z 9 c o CEMETERY OR CREMATORY AUTHORITY SHALL FILL OUT SECTION BELOW f`te .- e'L-F/CL-mac" �a 0 aT =- The deceased named above was buried'glz^•�i ❑ in the cemetery or crematory named in Item 23c.Burial was in Section IIIa. ° y LOT `L Grave 1 .I hay made t appropriate entrycemetery or crematory register. a /y 3 _t o -// e�N 0 ` w Signature 1�� L Date Signed: "'� vi to o o Z Sexton or other person in charge cc E s -� P This burial-transit permit must be signed abov by t cemetery or crematory authority.Where there is no full-time person in charge of the O a o Q cemetery,the funeral director may sign as sexton. ° V If burial tookplace in Maryland,thispermit must be returned within 1 n da s to the State Dept.of Health and Mental Hygiene re O T Li: Y €. Y P Y9' G a r o F Division of Vital Records, I- a E W oe 201 W.Preston Street, > o E U Baltimore,Maryland 21201. O m m Z ° V _ O a s o 0 • E W ~ vO 3 a. °-Z E O w 1 a�0 22o.1 certify that(I)(this hospital) tended the deceased from I i +Le , 19 . ,t° II 3 A-i+ 19 • ,that(p.(wel last saw the deceased alive on 19 .9,and that in(my)(our)opinion death occurred on the date and hour and from the causes stated 6 "°L 0, above,(I)(we)(did)(did not)V the b fter death. Z a ri _ r22b.SIGNATURE DEGREE 22c.DATE SIGNED Z= Z e, I' . ♦ ATTENDING MEDICAL STAFF ,�/ ij 3 F o PHYSICIAN ❑ DIRECTOR El PHYSICIAN PHYSICIAN 1-28-79 22d.PHYSICIAN'S NAME PR T) 2e.ADDRESS 6701 NORTH GHARI.E STREET • DR.H.WEBER M.D.. • TOWSON,MARY LAND 212 13o.BURIAL,CREMATION,REMOVAL 3b.DATE 13c.NAME OF CEMETERY OR CREMATORY 23d.LOCATION (SPECIFY); CITY OR TOWN COUNTY r STATE • DHMH-1650M 7/77 24.FUNERAL DIRECTOR In using this permit the funeral director certifies that he (VRA1$(4p NAME ADDRESS. has previously filed a certificate of'the death of this decedent. zx" q ,f X t y `� .b { 3Fr a .� +i to rK.,, - ya ' '-,. '.n.,..+- z+ r .r�rirs -iiY�M -_ +i .,i$ c,,.fir ,+s ._ • Ti,--t 4., 'wx.',4- _ r .c t h A 1 `�ib_ g -. k -..Y. y • 8 Y i.4 k -7 g sue{` = 'j ti �` \ a r }'+i as-.-7-, ,.} s, -0" .1,'g`r :. xiF , 5 ;k 'z.�a•s-:ith. :.� - `"` `�s "�•Y } �O i a a fr - - `+`ma's .,r, �,c.. i.wa',h."p •- ".*c-.n .n r', �,'" _"• --' '. '—'• • �+r i� --s �" ` �` i t^�.e r. t ? _ .. .>, �^' .. ._ .�. � .rsr vim. 3,. _.