Farrar, Robert! \
BUR AL BURIAL-TRANSIT PERMIT This permit must accompany remains to destination.
TRANSIT j1.NAME OF DECEASED DATE HOUR
R PERMIT )(Type or PdnO vex 2. ANp H OF DEATH
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3.PLACE IN-BALTIMORF, MARYLAND. WHERE PRONOUNCED DEAD ' 4. USUAL RESIDENCE(Where deceased lived.If Institution residence before admission)
�� A.STATE B. COUNTY
�" FULL NAME OF OF NOT IN HOSPITAL HOSPITAL OR INSTITUTION. C STREET , ,1
f Baltimore
3 .-1HW{ITAL OR ADDRESS OR LOCATION) �
ro J INnTUTION C.OTY OR TOWN D. INSIDE Cd1Y LIMITS?
Q m < r YES NO El) x
W s=it E.STREET AND NUMBER
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atu5.SEX RACE 7.MARRIED N A1EVER M 1ED $.DATE Of MIRTH .AOE as years If Undgr 1 Yr. 1 If Under 24 Hrs.
_ y p e ❑ last birthday) Months; Days r Hours n.
W WIDOWED❑ DIVORCED❑ ;4 k y r,; " r' 1 a ! 1 ;
12.CITIZEN OF WHAT COUNTRY?
Z I AL IOA.USU OCC AT(ON•(Givel'und of work'10B.RIND OF BUSINESS OR INDUSTRY 11. MIRTHPLACE(State or fo ga country)
0 0 C done dyirrno most of working life,even If retired)
t , 0 Z F.
13.FATHER'S NAME.p 14. MOTHER'S MAI9M NAME"
NN IM 1st ,; ,, ,' 'a .'"P .t4,.r:. '' a.. ' "''r'' * ' -,.�.. .,r. -."` r ,'
a Q W O ,� ..r. y.ftuaI+`Ti r f f#'" �/'Y ... 'r2 3�J�'.a*' rpr°{
G 15.Was Deceased Ever is U. S. Adored-forces? 6.SOCIAL 17.INPO&MAN DDRE ##
)Yes. unknown)(If es, give war or dates of services) SECURITY N.yO;.r {y �C u
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i p U. gy AUTHORITY FOR BURIAL, TRANSPORTATION, REMOVAL, CREMATION OR OTHER DISPOSITION
CC F- H I.
This burial transit permit, when completely•filled in attd bearing below the signatures of the attending physician and funeral director,
W C 0 constitutes authority for burial,transportation,removal,cr , ' or other disposition of the deceased named above.n.
I- z o CEMETERY OR CRE •RY AUTHORITY SHALL FILL OUT SECTION BELOW
C F<- O The deceased named above was buried 111.2
cremated ❑ in the cemetery or crematory named in Item 24C. Burial was in
C = u U �'Uw�l�Ar Crave_ I have :`the /- late entry in the cemetery or crematory register.
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} W W Signature w� / �,.,✓.t
z N e Sexton or other person in charge
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Z .- 'Ai
It1 u _ < THIS BURIAL-TRANSIT PERMIT MUST BE SI r ED A OVE BY THE CEMETERY OR CREMATORY AUTHORITY.
} F, u 1- W WHERE THERE IS NO•FULL-TIME PERSON IN CHA GE •F THE CEMETERY, THE FUNERAL DIRECTOR MAY SIGN
j Z F W N AS SEXTON.
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• - tr Z IF FINAL DISPOSITION TOOK PLACE IN MARYLAND, THIS PERMIT MUST BE RETURNED WITHIN TEN (10)1.
< i x u u DAYS TO THE BUREAU OF VITAL RECORDS, BALTIMORE CITY HEALTH DEPARTMENT, MUNICIPAL OFFICE
W = W io d BUILDING,BALTIMORE, MARYLAND 21202.
�0 vn C 11.• 22.I certify that(I)(this hospital)attended the sed _ " - :_ '. 19 f"'"'_.to_,..,a_. '___.__.19 i._f ,
g F F U < that(I)(we) last saw the deceased alive on ,,... 19, and that In(my) (our)opinion death occurred on the date
3 G _~ f
< V Z m NJ and hour and om the causes stated above. (I)(We)(did)jildtseot)view the body after death.
J Ill 2 C I- 34141 RE R. ! ... 23B.DATE SIGNED
= W t O. t €,.. 4 ,. kijef Amend; DMed. r❑ Slap ❑ , i wow* 9:6,
1- >- 1- d — N' es Phis. recta Phys.
J CC S 23 CIA S 33 A�RtSS
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er
4300 .11 ME(Type) '
DIG
S O 4 F- H 024 .REMA A 1AL CREMATION, 24M. DATE 24C. +I�CEMETERY es A RY 24D. LOC I N (City. town, or county) (State)
s t- f a,i'rt
q,✓ , - '7' P s N . York _
25A.DATE CO M HEALTH DE 255.NAME OF R t 25C.FUNERAL DIRECTOR AD STi
4'.. F .Ya1 �-� U it s
VS tag-REV. 1/1/ere RN USING THIS PERMIT TIE FUNERAL DI ECTIR USITVES�THAT RE NA$ FUD A CERTIFICATE B TIE DEATH OF THIS DECEDENT.