ML20138G294
| ML20138G294 | |
| Person / Time | |
|---|---|
| Site: | 07003029 |
| Issue date: | 04/11/1975 |
| From: | Delyzer H DELYZER, H. |
| To: | Mason J NRC OFFICE OF NUCLEAR MATERIAL SAFETY & SAFEGUARDS (NMSS) |
| Shared Package | |
| ML20136D106 | List: |
| References | |
| 0705, 705, NUDOCS 8512160282 | |
| Download: ML20138G294 (2) | |
Text
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' e s.' 81 y-Chief of Materials Branch x
ATTN:
Mr. James R. Mason f!)
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s Division of Materials and jf rl (o
5 Fuel Cycle Facility Licensing United States Nuclear Regulatory Commission
(
Washington, D.C.
20555 y,
v fmjy U3a Gentlemen:
The following information is submitted in application for a licence to possess special nuclear material contained in an implanted nuclear powered cardiac pacemaker.
I.
(a) Applicant's Name Mrs. Henrietta De Iyzer Addreas 373 Ieke Ltreet, i.pt 203 City Sault Ste PArio Country Ontcrio. CANADA National registry or Licence No. if any (b) The name, address and telephone number of the hospital, clinic or appropriate authority in your country to be contacted in e
case of an accident or malfunction of the pacemaker:
n Q N EL Name Lt. Ahuja, UNIVE!LITY HOSPITAL 0
Address ose Windormere Road o
City L0ndOD Country Ontario, CANLDA n
Telephone No.
610 674-c464 y
FM'ILY LOCTOR:
Dr. E. Bromborg, Doctors Bldg, r;ueen Ct.
E.,
Sault Ste Parie pi' II. Pacemaker Identification:
Ontario, CAN/2A. Phone 705 9 0 -1778 I
OWZ m a:U2 Manu facturer Modtronic Model No.
@ u N G-^1C"t91)
Q*
Serial No.
4Rold4N Nuclear Fuel Plutonium 238 CL.
Milligrams Curies E.L C
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_ _ cfII. I hereby request a licence to possess the implanted nuclear powered gIII.
I huvo to go to University Hocpital, London, Ont., for ry checkup on i
a e0 M ay 1975.
Y.o havo buon coing by Upper Michigun fron._oult Sto L rio, t a-8 Michigan, to Port Euron anu croc ing at, Sr.rnit.
It, t1koa about 9 hours1.041667e-4 days <br />0.0025 hours <br />1.488095e-5 weeks <br />3.4245e-6 months <br />.
g Wo will 1%vo here on da or ~0 May und return by J unc 3.
d,#J d:r-Our families live in Chathtm, (mt., unu rm take our holidays to vicit tho=
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the last, two nookc of August trc' elling tha nee veuy.
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Also we have toen going to Sault Eto M ario, Fichic.n, thre-or f<cr tin s a year for a Saturday af ternoon of shopping or viattire tha Locks. Usually a se-of-tJsmoc it. v-wvdAn m medde he,,, h e
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IV.
I will wear an identification bracelet to be supplied by me which is fire resistant and of durable construction, and which is engraved in English with at least the following information:
1.'
Who to not.ify in your country in case of emergency, including telephone numbers to call in the event of an accident, or difficulty involving the pacemaker.
2.
The words " radioactive pacemaker."
3.
Pacemaker manufacturer and model number.
4.
The radiation eymbol.
5.
The name of the bearer.
6.
Identifica cion (spelled out) of the radionuclide contained in the pacemaker.
V.
In addition to any identity card required in my country, I will carry on ny person an identity card to be provided for my use by the U.S. Nuclear Regulatory Commission (see attached facsimile of card to be provided), and when I leave the United States, I will return the card by mail to the U.S. Nuclear Regulatory Commission and indicate the date of my departure.
Sincerely, 2 ;iAb Q
/ E', / J-f U 2
Signature Mrs. Henrietta Do Igrer name printed or typed 0
,s 0
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