HomeMy WebLinkAbout1918 , - „ ~ •
i t 1.. - i I
LECAL FF.E ;1 00 CONNECTICUT STAT'E llEPARTMENT OF HEALTH
Public Hexlth Statistics Section-Hartford, Conn~eticut U.S.A. S'j~
Certified Copy of Deuth Record
II l. PLAC6 oF DEATH: (al State o[ Conneet~cut I 2. VSUA4 Rt-~!ae~ca or Detseuo: (a) $ttte Florida
1i <b) Cnanty i (c? 11a~vn ~(b) County (e) 'Ibwn (dl Ie Re+idence 1•i+ide
W I~ O + St,,._Iucie I Fvrt Pierce s City or Boioufi'h Limitt?
,f (d) Name ot kioepiul or'Ins.itation ~ (e) Street Number Y~"tl ~ ~O ?
Ut noc in • hoapital or institution give Street No. lIt ru:d. ¢+ve ioeation) It Yee, name Ci!y or
or ixation)
I ~0 '~kat Street 1111 Jaamine Avenue ~o~h ~QSCe
~ 3. NAME O~ ( FItsL) ( Midd~!) ~ ~ ~~~AL $LCUR~TY NUMti~
I Dsca~sro
' (Typc or print) ~'iZ'S'(.°@ W~ZCOX Sin~ki~ " ~
i i ~
i~ MEDICAL CERT1FiCATiOf~1 (Try~ or priat)
~I pERSONAL AND STA'CISTICAL PARTICULARS
~I 22. C~uss cr DCATN (Enter onl~ one cause ber box (~)(61 and(e)1
S. J[X f 6. RACE I 7, ~AR1tlLD NEVER MAARICD ry IIti76RYAl.
I ~ U PART I. DCAtH M'AS CAU3r0 BY: sETM'F.LN
i~~A18~.d ti1~'1~~i8 Wtoowea I;~ron~ Ixxcatnss C~~s[ oxser ~wn
DEATF{
~ 8. II MARRIHD, WIGOWED OR DiVORRD, GfYC MAIDRN NAM6 O~
Wtrs ae H~ss,?xn Arteriosclerotic Heart Diseas
~ Stephen A. Sinakie_
9. D~~re or (Mvnt6) (Day) 1Year) DV6 i0 (b)
I puitt Conditions.
i ~a~Y 3~ 1965 If anr. ahieb
a.re Arteriaacl~rosis
10. Drrr. or II~er~[ Acs (in yrnn ~f r.nder I year if under l day ~~yoye cause ~n•
~TaR• p last birthday) I Mon!hs Lays Houca Mins. (a), staitin¢
V the underly Dv[ io (e)
1~8t~ ~ 81 ( ~ ~ , tn=
11. 81ltsnrt~cs (Cicy or town) (State or foreiXn eountry)
I~ j ? Pnr.r ~I OTHRR $IGNI~f('AI:Y CONniTln\S CONTRIYUTING ~3. WAy
Wat~rbury ~jOL~LEC~ICIA{i T~ DEA7ii BUY NOT RrtATED TU T}iE T[RMINAL DIDiAEE /~VTO~EY
` CONDiT19N GIY*N SN PART I(O). p6gbRk~D~
]Y. (s) Usu~~ OCCI'PAiION tG~YC k~nd af v:ork done durinz mnat ot yes ~No Q
~ a•otkinQ ~ife even if retired)
A~ VO~ I Z(• $VRC~RT RLl.6~'AN7 TU C01D17i0n6 ftiPORTLD It( IT[K ~L2.
11
(b) Inou~reY o~ Bust~~s fa) tiame ot oDeration (6) Date yerformeQ
lE. (a) WAS DECLASEO A~~ETEI.AN~ YCS OC Nn ~ (b) T1NC 01 IT~J6'RY
(b) If yee. ¢iva war 25. ta) Acnnsxs SUtaoe liou:r,toe ~ Hoxr MoxtA. DaY. Ysar
Unit or Ship ? ~ ? I m.
y,4. r,,„~_ I,eRay Wilcox Ic) INJURY OtCVRR6D ir,t }>cece nr INJURY (e.p., ix or abort Ao,we,
(Citv or tuwn) (5!ate or fotti~n country) While st Not R'hile ~ ~a"'~' ~°~tory, ~trsst. o~'ice bidp., steJ
+ ^ w ork ~ at WorY.
I~ IS. BIRTlIPLAR. Great Barrin~on .°rmont
M~r~ex A~CC ~'1~bOC18811X ' <e) Cmr, Towx. oR Locenoti Couxn~ 5r~re
I i6. N~H•
tCity or tov~n) (State or foreign country) i
^
DESCRtlB H~W jN7UilY OCCUItY.dU.
} I'. E:1RTI~P~AiE ? ? IF,wter ~st~*e oJ in~r+y !x Psrt I
18. 11+~ORNANT'9 NASIL qr Par~ ll OJ ittwl 2t.)
j Stcphen A~ .~'`.inskia 26. I HEREBY CEFt7iFY. that i aeLended lhe deceued f~om
~ I~. BVRIAL, C~X~1R'I~C~RRL~~~R~L DitP AuQ• ~ 14~ - 19 . tn 19
Cemetery or C1'lflflTDTY S y~ v Qt~ Dh ~ 8 tkut l laat saw the dKttlNd af~ve on. 19
Placc P~.~f21V~1~~ COTII1CCt~CLit snd that d~ath ia said to h~rt oanrrri nn._.sd3i.l.y ~T196~
ZO. NAM6 O? EIIML7M6lt ~r Bonr M~AS ENBALI[LP Licease number ~ xt 9;4~ A~ m.
T. Fiabert ?~ltiitan Jr ~ ],s0'j ~ ~7• $iCNATVRi o~ FHY'STCIAT(
zt. o ~ru~s xs~w aKS~~.MSR.oR tacsvsso Fut+uw DTRacYVa Narold H4~]c"ii1A M.D. M.E.
~c.d
i~ A~dws P1~inville~ rmecticut Nsx Lcmdon Conn. n.~ 7-319136~
T'HSS CERTIFICATE RECEIV~ FO ECp ON ~ : . , /f , R 'LG~STMR
A•~1 3.465 ~ r • s~ b T R08t,h
. ,
i cert;fy that t6i~ ia x trus trao~cript of the inforrostian`~,'y~w`ibe dertTi-sd~ord s~s recorded in thi~ oECsce.
~ t~ , o .
t , ~ 7 i , .
' •'lj 7
~J'~ . . ~
Atteat:-:.....~.~.ZRt~C.......a.~..•~"Gi~nAi !i+r~
~.,~q~rt1w':'.y:d-+~+/+~~• ~riistrrt of Yital St~tisties
a, .
Dated ............A~i~.. .........................TOMA of........~~f~~1A~~..~V.~t"a~.C.L~~......,........................................
NOT GOOD WiTHQUT' SEAi. OF CERTIF~1'ING ~FF~C~K~`;U
i~'urm V.S. 18~_ V V t
arrr~r~