Dickinson, John oVR1AL - 1KMPIJII rum'I: tHIS PERMIT MUST ACCOMPANY DECEDENT TO DESTINATION'
`., _. 3
BUREAU OF *fate of Delaware
VITAL STATISTICS DEPARTMENT OF HEALTH AND SOCIAL SERVICES
DIVISION OF PUBLIC HEALTH
c •room LOCAL REG. NO. STATE FILE NO.
o
>`.G m 1.PLACE OF DEATH
- ^j 2.USUAL RESIDENCE(w 1111, TS.D DfcRAsfD L vED,N NST.RAT oN,REs DENCE RfroRE ADM ssioN)N.C.
C m- O A.COUNTY i,yew Gastl.e DELAWARE A.STATE .i.Jel . a e B.COUNTY
C C C.CITY OR TOWN(If OUTSIDE CORPORATE LIMITS,WRITE RURAL AND GIVE NEAREST TOWN) ZIP CODE C.CITY OR TOWN(f OUTSIDE CORPORATE LIMITS,WRITE RURAL AND GIVE NEAREST TOWN) ZIP CODE
- a . O
s : a. Wilmington
Wil in to --19801 t1Wilmington -- 19806
1 . 00 �Q TAa9571 4OvNOs Lr �'® i Y3WITT l L,$TREE A SS Z et3f Devon p 'QY�-SIDEZEsW N CITY LIMITS'?
21171
W 200 S, Adams tr et YESX] NO❑ 201 Pennsylvania . venueYES❑ NO❑
° N OO
E 3.NAME HEST MIDDLE
r -• G . OF LAST {�, 4.OF
MONTH DAY
♦ >{ tYEAR
o E E G (T EcEOR PDNTI .3 o.i 1. Dicki sson DEATH
September 23 , 1�`/ 9
O E 5.SEX 6.RACE 7. NEVER B.SOCIAL SECURITY NUMBER 9.USUAL CUPATI N-SIN RETIRED E'n (-ITIZEN Of WHAT COUNTRY
d m C 'White MARITAL MARRIED WIDOWED y. RE
V O Male W ai a STATUS '— -O Q eLZ Y� "-`- f�oa.,�E c�ETr
C G MARRIED X DIVORCED 7 3-908 en. Mgr - Pin h 'U.S.A.
� 0 E 11.DATE OF BIRTH 12.AGE(LAST elrtnDAr) IF UNDER 1 YEAR IF UNDER 24 HOURS 13.PLACE OF GIRT 5�11 R[�it1cN �1 WAS DEPg IF YES,GIVE WAR
3 F- m O MONTHS DAYS HOURS MINUTES l���' 'WAS DECEASED
°; ` Nov. 24, 1906 72 New York EVER IN U S. No
FORCES?
j 7 E ° 15.FATHER'S NAME 16.MOTHER'S NAME
m m O._
sgiWalter T.
Jikinson Sarah Barnes
17.NAME OF SPOUSE
P~O 2 IB.INFORMANT •
g E € cCL
Betty Bowen Dickinson Betty B. Dickinson--Wil��inc(ton, DE
° ` ` AUTHORITY FOR BURIAL, TRANSPORTATION AND REMOVAL
c . °.4
c= E This Burial Transit Permit, when completely filled in and bearing in item 26 the signature of the Medical Examiner or
`` L E t; his Deputy and the Funeral Director becomes authority for Burial, Transportation and Removal of the above named
mz ° " m ``'
v c 5 n Decedent.
.W o c This Permit is not authority for cremation. Separate authorization must be obtained.
-d = "'m CEMETERY OR CREMATORY AUTHH RITY SHALL FILL OUT SECTION BELOW
ae °= 'c The Decedent named above s buried cremated in the cemetery or crematory in item 29.
m3 e c 3„ Burial was in Section :27 Lot 7 rave The appropriate entry in -Cemetery Q Crematory 0
registry has een madek- t �t � c.4---Y' c 1�..iC. ..- �' r�
° . ; .V m Signature . — -n-" w7o >' J// /979
i ° .« a aai \ Sexton or other person in charge (� Date si ned
9 9
=13 H P. This 8 rial.Transit Permit must be signed above by the Cemetery or Crematory authority. If no
I t m w °. full time—Berson in charge of the cemetery the funeral director may sign as sexton. See mar.
- w1 ° „
I- . ° O. ginal note.
if.eo a)d Q
26.
p S c E E`r o I CERTIFY THAT I TOOK CHARGE OF THE REMAINS DESCRIBED ABOVE, HELD AN AUTOPSY n, INSPECTION 2, INQUIRY , AND IN
p x c o v MY OPINION DEATH RESULTED FROM: NATURAL CAUSES 0, ACCIDENT ❑, SUICIDE j, HOMICIDE n, UNDETERMINED MANNER 0.
eg 19
W N e. : •. . U
G a v•:4 „ V SIGNATURE ;',41.-te �' CtnEF MEDICAL EXAMINER Ell ASSISTANT MEDICAL EXAMINER E DEPUTY MEDICAL EXAMINER El
W tC awr Galicano B. In t,tito, "i.F. DATESIGNED �'� 4/jI`/' F
°J
Q M Q 4_ .Y\ 27.BURIAL,CREMATION,OTHER•(srfclfr) 28.DATE THEREOF 31.FUNERAL DIRECTOR'S ACTUAL SIGNATURE r-Y /
. r J t
_ U �OC 01 J
W .z o :.. ^re=latit3z Sept. 25, 1979 Chandler l r funeral iiarnesA% •
.ELL E« 3 29.NAME OF CEMETERY OR CREMATORY 32.FUNERAL DIRECTOR'S ADDRESS •
0 o Hockessin Crematory Colapany 2506 Concord Pike; W-ilm. , Di 19803
30.LOCATION(CITY,TOWN,OR COUNTY) STATE 33.DATE RECEIVED BY REGISTRAR 34 REGISTRAR'S SIGNATURE
Ilockessin, `:)elaware