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HomeMy WebLinkAbout0212 ~ CONNECTICUT STATE D~PARTMENT OF HEALTIi • s.b~,~ ° 515 9 • F~~alt6 Stati~tie• Section-Hartford. Co~~eeticrt U.S.A. ~ • Certificate of Death 7 ~ Legal Fee: $ ~ 3~~ (i1 St~t~ el Cenneelknt 2. Vav~~ Ri:~i~eNCw er D~Ce~~ts: 8t~t~ ('iQ~,~• (?1 Csrel~ (el 'rsw'* ~ (b) Ceuntr I fel 'llewe (dl I¦ ~'~~ra in~ide i` ' ~ ¦ City or Elo~ouKif Limiu7 ~,+I HA'(l~i _ NE{ni_HAVF.N td~, d HAVF.D' NE'el,.$~VENi - td) Nime ef Ha~pit~l or Inttiwti.~n le) Strect N~~Mber /Ya ~ No ? (if wot in e Aeapitsl sr inrtltntbu tit~ Stnet Na 11l ron4 t~Y~ ~R~) ]f Ye~, n~me City or or i~~uo~~ CO~t. ~ B°~ HAVII~T ~ G~tACE NEW HA~IE ~ i. x~MS o. (First) ~R~~ (Niddk) ~i..a. b .L sscv.~nr xur.s. ( S?ettesso - -~J R , - ~ lTsDe or arint) ~~~U~ ~~/:rl~c • r i~' '1~ ~ ;,'MtS~ ~ TI 1 K *riwt) ~ PEItSON/U. AND 3TATt3TlCAL PAI~TICULARS ~ • ~ ~ -.a~'- r ^3 Csv¢ 8~ i~t (Ln bo: ~nd[e) SiX RACt ~~r' . ' p'~. . ' iNTCRYAI. I 7. ii~utsa ~ Nsrsa Mawso ~ P~~r ~.'bs~lHj~ ~y~s 8'r:~, t~' ~~r~'~+'. rV~oowia ~ J~nor~ 1~ xC~?u~ ~il ~a~ ~ ~ ~ ~ - ONDiAT1(IiD R I/ MA11qF.f. W(60Mt~ Ot DfrO~Li~ YiR ~IA10~1r NAMt OI .~`8~I I . r . Wf/'~ OR HVpwMO ~ • " • ~ 9. ~r~ o? (MoatL) (D.r) (Year) . Qy{r• ~~(11) 8~~'~ DeAm Condleions, ~ - y~l~i' Z(~611 ir an>. rrhie6 ~ . cave rise W l0. Dass o? Bsn7t~ Aes (in ye~n ii undrr 1 ye~r ' if a++der l d~~, ~M~ ~ +K-o-+~ lut birtlda~) xont~ Da~a Noun Hinc. statinx ~ the underi~• DUL 70 (e) ~ ~ I in~ eauN - , t~,aY x6, ~903 61 I?d,~. • il. 8ta7H?W?pt (Citr or Wwn) (Sbte or torei~n eountr~l I 1 P~nr il OTH6A S1CN1 c Nt GINPITp~NS ONTIUYUTINC 2J. Wws Kishenev Russia TO DEATH •VT N07 }I 7U 7Ni TitNiNAL (1~SiA AVTO~SY CoNO~r~q~ CtvsH wrtr i(s1. p~RroRkr4? 12. (sy Usa~t OecurwrwH (Cf~e kind of ~vork dont durini moct ol ~x~ ys ONs,~ •rorkin~ lite e~en if rstired) /r~ ~~~'~.r.Lac~ies~L~~'YLa.r ~7~'iOI~A 24. SU~CLaY RR.irANT TO CONDITIOK~ RElORTiA IN ITiI[ 22. ~ lb~ i~o~ Suuxes~ (~1 N~rne o! oDentton tb) D~te pcrterm~d ~ ~ Mo13.nos, tlaw Haven,Conn. ~ C~lost I : li. ta) 1Ves Duxwass e VtTSitaht Ye~ or Ho NO C!~-f~li-~ ~ ; _ I (b) TINL OY INJL•ItY ' lirj It T+.+. ~he war - ~:S. (a) ACtmsrT Svipus wccos ~ Nerr Afo+~tl~. aaY. Yesr . I m. ~ ~ ~ ~ Urtii or $AiP ~ ? -~U ~ N,,,,s Isadore SC t- i~e1 INJURT OccuRRSO rd1~ t~~~} [ Ot INJURY t..~.. iw or ab~~it Avw~, ~ <Gftr or t9~+h11'_ .~pta or,tb~ira eo~ntrr) While st Not While 1~to+Y. ~trs~l. odies b1dy.. t . B3RT11/LAfL i1y~li ~ ~ ~ ~ ` f Su~B µOPI[ ~ at Work M~ioser rf;' - - ~c) Crrr. TowN, os LocenoN CovNrr Ssers " Ii. NAM , • ' ~ ~ (GIO M : [T ( , te'os lortisn eountrs) • (t) D6aCatre Hnw 1N~uRr O~c~M+~so. ~ 17. DIR7IIPLALt J"~ -~~~~5 .~n:•r Ratr~t ej fwi~ry iw P~rt ! ~ ' _ _ _ ~-o~! T~ . JI. Il110RMAfST's N~xs~ > > ~ -1~ ~ or Pa.c N o11e~s. st.) - :6.. f{EREBY CER'CIFI. tbat i~tesnd tT~ d~eeued trom ~ ~'L~' b ~cHerb2~ 'i t !cl !1 !+L.~ L. " . ~ ~L1- ....t 19 w /I 1~ ~ 10. SwuAM ~~at~~r~RtKi1M~JQ~~.~.1~L.~ 1~' - - - - ~ C~mNt!y~et~lt~~~~Awtb~F~f'~.~~r1~'~G~l.~L~'~'~ al P~r1r that i WC taw the daeued •?;v~ on 6 19 f~ ~ i'Iseo'; •'i a - and that dath is uid W b~vt acurred on ~ 20. H~M! O/ EMMLMt11 R BOOT M'A~~lA L0 Lielnfl numbe st ~%L~S, m. H:1.~RY t~~"~:u 2T. stcx~tv or xrwww 3."" •ELta t + 21. SNGNRTY:l OF ~s„sr+r EM~ALM6K cs U ssa Fu D cro~ ~'~Ti"~i.~1.,'u. '~~T'~r~_Hdl 'j IZVCi • ~.1~ L' / i ,i_ AJdra~G~~~ C160Y'P,$ .S~'i. Addres~~ ~te °~ylv ~ I~ TH18 CERTIFlCATE RECCI ~ E ~ ~ Rcct~fl R • 1 J1~~e 21. 1961~ ~ °Y - - ~ }'UKM V5•~ ~ :t6iiYr' . . r-- - - - . .....r~ . . . . . . [ certifT t6at this i~ w tru• tr~ useript of t6 bformation the esth ree a~ ra rdad in thi~ o ce. I y : t~•V ~f:~:;~,~'~.. ~ _ /\tteiti ~eristr~r o Vit 1 Stati~tica D~t ~ 4ie~ ~7;t~'~'~ . ' ~j~~! E D E D . ~ ~ . . . ~~yG,.~ 5. .~.:..,.r.y..... .Town of........... . . .~.~....y,ti*..L ~~~~:7~tLIQ1.._T~~~~ b 0 K ~_~NOT GOUD Wi3'HOU7 SEAL O~ CERT~F'YiNG OFFICIAL Form'0.~.:1b~ r ..~.~~~~'~;~:-::-;t: - _ . . _ . ,i~+~ 26 ~i ~ 1 Z g ~:sr. .4,~. :.c"~~ 1~# Ii . ~i~~•~• \'J ~ ` \ ~ ~i.~ r•' ~~-z ;FV~;i.~QS. CLERK a ° ~ ; " ~ ~~T'. i~ ~~~U~t~Y, . : - ~ . - . . , . _