Meron, Harriet 3 STATE OF MARYLAND -
FOR DEPARTMENT OF HEALTH AND MENTAL HYGIENE
BURIAL 1 - STATE
TRANSIT REGISTRAR BURIAL-TRANSIT PERMIT This permit must accompany remains to destination
PERMIT 1.DECEASED NAME FIRST MIDDLE LAST 26.DATE OF DEATH MONTH DAY YEAR
Harriet R� �j T H Heron June M lb.HOUR(�
(TYPE OR PRINT) ti�•Jl2.y�� Meron J ne 18, 1986 9:00 A
3.SEX 4.RACE S.DATE OF BIRTH 6.AGE (IN YEARS LAST BIRTHDAY) IF UNDER I YEAR IF UNDER 2n HRS
FFemale t
e White J y 10,AY1912EAR 73 MONTHS DAYS HOURS MIN.
�+{'��.�� f� YRS.
76.BIRTHPLACE
- (STATE OR FOREIGN 7b.CITIZEN OF WHAT COUNTRY? 8. 9.BALTIMORE CITY OR COUNTY OF DEATH
w E• ms° H ii7Li{ U.S.A. WIDOWED MARRIED NEVER MARRIED D RRIED 1-.1 Prince George's County MD.
x 61 o a 10.CITY OR TOWN OF DEATH 11. NAME OF HOSPITAL,NURSING HOME OR OTHER INSTITUTION 116.USUAL OCCUPATION 12b.KIND OF BUSINESS OR
15,
r - �a, Cheverly 32`I ° �IVE� ' RR ,`1�" trio" ` 113'Yr Falls
r v Ceuttal Hies itA
O o O. USUAL RESIDENCE(IF NURSING HOME OR OTHER INSTITUTION,GIVE RESIDENCEy�D BEFORET ADMISSION) p��twist( �p pp�� ry AC
a• 'o N o >Z3P Fjan I13b.C4�JN If V Cr1r I d.IN DE CITY LIMITS? It3�TUL Le.LCiit Z1i g`Liiie 28785
> -5 0 c NO
Q 3 o a 14.FATHER'S NAME IS.MOTHER'S MAIDEN NAME
O � o Fred MIDDLE Potter Mae C)DLE Mbar
W 11 -O- j'j� Patter laac'• ;{
g' -° o "E
O o . i 16a.WAS DECEASED EVER IN U.S.ARMED FORCES? 16b.SOCIAL SECURITYQ NO.I� 17.INFORMANT
��. �} ADDRESS �t yyyy t
P 'O - 2 OYES,NO OR UNKNOWN) I (IF YES,GNE WAR OR DATES) I�I 2�1922 Janet anski (I3au titer) Sum! as #1 +�'
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1 3 ° AUTHORITY FOR BURIAL,TRANSPORTATION,REMOVAL,CREMATION OR OTHER DISPOSITION
.tv a .4 v This burial-transit permit,when completely filled in and bearing below the signatures of the attending physician and funeral director,constitutes
I- -o ° 2 authority for burial,transportation,removal,cremation or other disposition of the deceased named above.
ZO 3 o CEMETERY OR CREMATORY AUTHORITY SHALL FILL OUT SECTION BELOW
vt •o 6 o The deceased named above was burred® cremated ❑ in the cemetery or crematory named in Item 23c.Burial was in Section
TT
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cc
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d a «- .Lar 31 Grave 2 .I have made the appropriate entry in the cemetery or crematory register.
3 t of
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�t�1 �� ate Signed: 6//3/
Fih
tN o o w Signature
vi a r ° Z Sexton or other person ie charge
rxO - m 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
t J• el o'o Q cemetery,the funeral director may sign as sexton. _
uus o E s LL If burial took place in Maryland,this permit must be returned within ten days to the State Dept.of Health and Mental Hygiene
Q o_ 0 nee Division of Vital Records,
O 201 W.Preston Street,
~ a ' V
o j o Baltimore,Maryland 21201.
O N E D Q
W V Z Q -
a
0 £- cWc
iF S 01 C
a._
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c E N a
12a I_certify that 111-(th s hospital)uttered/le "cea Ted from • , 19 ,to. -- .k9 r.4✓gt-441#Wei*Lost-
'-';'
0..x 3�--J"-saw the de easd alive on V - I 19 `i ,and that in m our opinion death occurred on the date and hour and from the causes stated
E O m $ / ( y)(our) pi
t F Y above,(II( e){did)(did not)viewthe body after death
1 Cl.... 0 726.SIGNATURE, jj 1 DEGREE 21t DATE SIGNED
U' r f 1 + t I = -- ATTENDING MEDICAL STAFF • ,
Z °a- `"�%" PHYSICIAN -.DIRECTOR❑PHYSICIAN❑
3 g Z ° 22d eRI PHYSICIANS NAME ltVR,E,O NT) - }. /4.- _7,, 27e-tDD1R SS . y J T+' - y / s I 1; 7 - ii .
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23a.BURIAL,CREMATION,REMOVAL 23b.DATE 13( NAME OF CEMETERY OR CREMATORY 23d.LOCATION
(SPECIFY) t 06/23/86 t. A plonsus Cemetery Qt bnry Wa n s'Y irk
2g E # i s 5 ns Fuucsal ! •I`y ry 75a.DATE RECD.BY REGISTRAR 75b.REGISTRAR'S SIGNATURE
DHMH-16 60M 7/84 4739N` )timbre VeA a Hyattavhi le, Md. 20 81
(VRA15,4) 7 .1� O ++.7