Miller, Richard For Burial-Transit Permit(This permit must accompany remains to destination)
State
Registrar Reg.No.
1.Decedent's Name(First,Middle,Last) 2.Date of Death 3.Time of Death
Month Day Year
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4.Facility Name Of not institution,give street and number) 4b.City,Town or Location of Death 4c.Country of Death
5.Social Security Number 6.Sex 7.Age(In yrs.last birthday) If Under 1 Year If Under 24 Hrs. 8.Date of Birth 9.Birthplace(State or Foreign
Months Days Hours Mins. (Month,Day,Year) Country)
116-24-5472 1 L T4 2 0 F 87 Yrs. 02/02/1927 NJ
Usual Residence of Decedent 10b.County 10c.City,Town or Location 10d.Inside City Limits
10a.State 1 Yes 2 LNo
MD Frederick Frederick
(0 G 10e.Street and Number 10f.Zip Code 10g.Citizen of What Country
0 d 110 Burgess Hill Way 21702 U.S.A.
o
i7 11.Marital Status 12.Was Decedent Ever in U.S. 13.Was Decedent of Hispanic Origin?(Specify Yes or No- 14.Race-American Indian,
.c74 1 0 Never Married 2 XMarried Armed Forcg�s? If Yes,specify Cuban,Mexican,Puerto Rican,etc. Black,White,etc.
s T.G.11 0 Yes 2. 1 No 1 0 yes 2�y No Specify: Specify: r
r 3 0 Married but Separated YiWill 11 to
N a o 15 4 0 Widowed 5 0 Divorced
-- -c >, 15.Decedent's Education 16a.Decedent's Usual Occupation 16b.Kind of Business/Industry
m Q (Specify only highest level completed) (Give kind of work done during most of working
-o life.DO NOT use retired) Veterinary
a .0 d 6 College Veterinarian Medicine
m 2 o f 17.Father's Name(First,Middle,Last) 18.Mother's Name Prior to First Marriage(First,Middle,Last)
. a E 0 William M. Miller Catherine E. Schotte
® 8 U m 19a.Informant's Name/Relationship(Type,Print) 19b.Mailing Address(Street and Number or Rural Route Number,City or Town,State,Zip Code)
X .8.'' Margaret F. Miller 110 Burgess Hill Way; Frederick, Maryland 21702
ma
m a 20a.Method of Disposition 20b.Place of Disposition(Name of i Date 20c.Location-City or Town,State
N 1 X Burial 2❑Cremation 3 0 Entombment cemetery,crematory or other place) 1
tQ 4❑Removal from State 5 0 Donation 6 0 Other(Specify) Pine View Cemetery : QueerisbuLry., New York
3 o i 21.Signature of Funeral Service ce a 22.Name and Address of Facility Marzullo Funeral Chapel P.A.
oo ► ;Liza, J, 6009 Harford Road Baltimore, Maryland 21214 I
U -0 O
ro Q Authority for Burial, Transportation, Removal, Cremation or Other Disposition
c $ This burial permit,when completely filled in and bearing below the signature of the attending physician and funeral director,
0 0 0) m constitutes authority for burial,transportation,removal,cremation or other disposition of the deceased named above.
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0 in m x Cemetery or Crematory Authority Shall Fill Out Section Below
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co N c T The deceased named above was buried 0 cremated in the cemetery or crematory named in item 20b.
a 1
CC0 a 20 Burial was in Section t/t(1Ct.CL L a_.- __Al r Lot Z 3 74 Grave
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g a8 .2 co I have made tt'�e appropriate entry in the cemetery or crematory register.
® o .c 0 t Signature d E�J0--d�-C-Q - e'' Date signed /z/q/2.401f-
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N o c Q Se on�r other person in charge l
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v ' 0 a, m This burial transmit permit must be signed above by the cemetery or crematory authority.Where there is no full-time
0 8 E4 person in charge of the cemetery,the funeral director may sign as sexton.
152 a z a`) o
ToN o If burial took place in Maryland,this permit must be returned with ten days to the:
a) E . m Maryland Department of Health and Mental Hygiene
,- a a o i° Division of Vital Records
o E .D 6550 Reisterstown Road Plaza
G c 2 Baltimore,Maryland 21215
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~ c c 29a.Certifier 1 0 Certifying Physician:To the best of my knowledge,death occurred at the time,date,place and due to the cause(s)and manner stated.
32 o a (Check 2 0 Certifying Nurse Practitioner.To the best of my knowledge,death occurred at the time,date,place and due to the cause(s)and manner stated.
'L only one) 3 0 Certifying Physician Assistant:To the best of my knowledge,death occurred at the time,date,place and due to the cause(s)and manner stated.
40 Medical Examiner:On the basis of examination and/or investigation,in my opinion,death occurred at the time,date,place and due to the cause(s)and
manner stated.
29b.Signature and title of certifier 29c.License number 29d.Date signed(Month,Day,Year)
30.Name and address of person who completed cause of death(Item 23a)(Type,Print)
State 31.Date filed(Month,Day,Year) 32.Registrar's Signature
Registrar
DHMH 17 Rev 07-2014