William D Misfeldt@
FOR DEPARTMENT OF HEALTH AND MENTAL HYGIENE
1 - STATE
REGISTRAR BURIAL -TRANSIT PERMIT This permit must accompany remains t® destinati®n
DECEASED NAME FIRST MIDDLE LAST 2a. DATE OF DEATH MONTH DAY YEAR Th.
TYPE OR PRINT)
i L)
3. SEX 4. RACE „ 5. DATE OF BIRTH 6. AGE UN YEARS LAST BIRTHDAY) I IF UNDER I YEAR If UNDER 41 HRS
MONTH DAY YEAR f�ONTHS DAxS HOURS MIN.
u . ,
YRS.
70. BIRTHPLACE ( STATE OR FOREIGN 7b. CITIZEN OF WHAT COUNTRY? B. 4. BALTIMORE CITY OR COUNTY OF DEATH
COUNTRY) MARRIED=❑ NEVER MARRIED ❑
TRY) 18
.._ WIDOWED❑ DIVORCED ❑ ''-' =e --,T ;g-r-Yx MD.
10, CITY OR TOWN OF DEATH 11. NAME OF HOSPITAL, NURSING HOME OR OTHER INSTITUTION 12a.. USUAL OCCUPATION 12b. KIND OF BUSINESS OR
(IF NOT IN SUCH FACILITY GIVE STREET ADDRESS) (TYPE OF WORK FOR MOST OF WORKING LIFE) INDUSTRY
"F^' a.._ ✓s. _„ !-._-'}ron >aa -x m^+ r., s-. to,., ,b,— 1 .dot
USUAL RESIDENCF (IF NURSING HOME OR OTHER INSTITUTION, GIVE RESIDENCE BEFORE ADMISSION)
13a STATE 113h COUNTY I13c. CITY OR TOWN 13d. INSIDE CITY LIMITS? 13e STREET ADDRESS t�
a;. "E YES ❑ NO ❑ Dr iv
14. FATHER'S NAME 15. MOTHER'S MAIDEN NAME
FIRST MIDDLE LAST FIRST MIDDLE
LAST
16a. WAS DECEASED EVER IN U.S. ARMED FORCES? 16h.SOCIAL SECURITY NO. 17. INFORMANT ADDRESS
(YES, NO OR UNKNOWN( (IF YES, GIVE WAR OR DALES)
AUTHORITY FOR BURIAL, TRANSPORTATION, REMOVAL, CREMATION OR OTHER DISPOSITION
This burial -transit permit, when completely filled in and bearing below the signatures of the attending physician and funeral director, constitutes
authority for burial, transportation, removal, cremation or other disposition of the deceased named above.
CEMETERY OR CREMATORY AUTHORITY SHALL FILL OUT SECTION BELOW
The deceased named above was buried ❑ cremated ❑ in the cemetery or crematory named in Item 23c. Burial was in Section
.Lor --Grove—. I have mode the appropriate entry in the cemetery or crematory register.
Signature Date Signed
Z Sexton or other person In charge
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
Vcemetery, the funeral director may signas sexton.
If burial took place in Maryland, this permit must be returned within ten days to the State Dept. of Health and Mental Hygiene
f- Division of Vital Records,
W 201 W. Preston Street,
V Baltimore, Maryland 21201.
B
V
11
220.1 certify that (I) (this hospital) amended'thedeceased from - _ - 19 =" to = 19 •�` , that (I) (we)last
saw the deceased alive on 19 , and that in (my) (our) opinion death occurred on the date and hour and from the causes stated
above, 1) (we) (did) (did-notl view the body after death.
22b. SIGNATURE - DEGREE 12c. DATE SIGNED
ATTENDING MEDICAL STAFF
PHYSICIAN DIRECTOR ❑ PHYSICIAN ❑
22d,.PHYSICIAN'SNAME (TYPE OR PRINT) 11 e.ADDRE55
23a. BURIAL, CREMATION, REMOVAL 23b. DATE 13c, NAME OF CEMETERY OR CREMATORY 23d- LOCATION
(SPEC;:: CITY OR TOWN GUNT1 SIPTE
Burial
DHMH- 1650M 1/81 24_ FUNERAL DIRECTOR 25a. DATE RECD. BY REGISTRAR 256. REGISTRAR'S SIGNATURE
(VRA 15, 4) NAME ADDRE as