| MARYLAND STATE DEPARTMENT OF HEALTH CERTIFICATE OF DEATH # 13582 |
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| NAME OF DECEASED: | Ada E. Perine |
| PLACE OF DEATH: | Masonic Homes Bonnie Blink Cockeysville, Maryland |
| LENGTH OF STAY: | 14 Years |
| USUAL RESIDENCE: | Narragansett Ave. 58.3 Pittsfield, Massachusetts |
| SEX: | Female |
| COLOR OR RACE: | White |
| MARITAL STATUS: | Widowed |
| USUAL OCCUPATION: | Housewife |
| DATE OF BIRTH: | May 9, 1875 |
| PLACE OF BIRTH: | London, England |
| AGE: | 92 Years |
| CITIZEN OF WHAT COUNTRY:? | USA |
| FATHER'S NAME: | William Hall |
| MOTHER'S MAIDEN NAME: | Laura M. Powel |
| INFORMANT: | Masonic Home Cockeysville, Maryland |
| DATE OF DEATH: | October 1, 1967 |
| CAUSE OF DEATH: | Chronic Monolytal Leukemia |
| CONTRIBUTORY CAUSE: | Broncho-pneumonia |
| CONTRIBUTORY CAUSE: | Chronic Brain Syndrome Cerebral arteriosclerosis |
| CERTIFICATION: | I certify that I attended the deceased from August 15, 1965 to Sep. 30, 1967, that I last saw the deceased alive on Sep 30, 1967, and that death occurred at 2:45 P.M. from causes and on the date above. |
| PHYSICIAN: | Jamshid Hamed, MD Masonic Home |
| PLACE OF BURIAL: | Oak Lawn Cemetery Baltimore, Maryland |
| DATE OF BURIAL: | October 4, 1967 |
| FUNERAL DIRECTOR: | William Cook-Brooks Towson 1050 York Road Towson, Maryland |
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