HomeMy WebLinkAbout1075 ~ ~ ~ ~ ~ i ~ ~ CERTIFICATE
OF ~~ATH ` ~ `
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` MICHI6AN DEPARTKENT Of NfALTN ~~{;A'7~,~/ /'~l f"~ ~
Ylul R~wrds S~edon _ ~
BIRTH Na L.«~ n~. w
I 1 PLACE OF QE/1TH ~ 2. USUAI. RE31bElICE (Wp~cr Gc~ud lt~~d. It Inttltutlon: rMld~oc~ Ntor~ ~q?dm.~ ~
COUKT1f j) STATt 1. COINtTY r
~,,~t?'1-'l;ri ~tj^~'~~''~`i2! ~~i':Z~3II~ ~
b. GT{' ~1! out~ld~ cocoor~t~ 1lmtU. wrfta $L'SAL ~n.1 ct~e I C~LEM6TN Of 1~ C. TOWNSHIP, t:ram~ at1 4. G Reatdence ~tthtn tlm ~ ol ~
Q OR toMO~hfol STAY Itn tnl~ oluet ~'~,I CITI' OR ¦ efU or tneoruor~tre rtlia'E'eY
~ !I VILUSE ~ ~ ? :rl ~`q i +I YIUAGE 1 f01+ t my~. I ra ? ho ~ ~
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~ ~ d. FULL MAME OF ~I: oot ln ho~ptul or In~tltullm. d~e rtrert addren ot lotaUonl i~ i. STREET (I[ rnrai. ~i~e foc~tloal
HOSPITAI OR i~ ADDRESS 4
W ~j 11i5TITUTION G T,.~ 1 :7 j j~~i;.~ ~rp r'f{~.d~' t
t. --t~~,P_ S -•7ST.~_~~ ~
Z ~I'~. J. NAME Oi ~Ylrni v.ilf~ad:ei ~y------ e. ~Luu 4. DA7E~ 1)taote~ tD.r~ !1'e.ri
DECEASED OF ~
I~ iT>:encFcln~) f DFJITH ~
~ ~;r~lter S. 17+~~ne 3J ~t,inn I ••av 1~, 19K9 '
W S. SEX 6. COLON OR RACE I 7. MARRIEO. NEYER MARRIEQ, 8. DATE OF EIRTH 9. A6ElIn tetn lf under 1~ru If oni:r tir~_ `
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WIDOWED, OIYORCEO IScalt~l laat Mr~~~t1 ~la~th~ Lvt liocn i 31~0. e
Q ~ .,,~1 e ; 'r,'?-ii te ~ •,arr~ ~ci ~_1?_i f~~l ~,8 ~ I ~
'n 10a. USU?l OCC~Ph1~CN t:: i k ~ 106. KIMD OF BUSfNESS OR IMJUSTRY ; il. dIRTHPLACE ISC+ce cr to:e!~n caantril 12. CliIZiJ1 Of WNAT COUMTRY? t,
~y, :r.e d~_r r r.:~~~=t o, .wle,~ lif .e ea 1! re treS~, ~ p.
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~ ' 1J. FAIHER'S i1AME ~ 14. MO1kER'S MAfOEN NAME 15. MAME OF HUSlAMD OR WIFE 6i ~ECEASED ~
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~ z ~~a ~+~,on I~„i•
't~- _ L'~f:~oti.m f~il3red ~
Q ' 16. WAS DECEASEO EYER IN U.S. AHMED FORCEST 17. SOCIAL SECURITY N0. ~ 18. IkFORMApT'S NAME AQt7RESS ~
Isr Y (7'n. no. cr cnkrawn) i(If sti. 7Nr aac ~r d~t~~~ c! ~entce:~ I t
~ 4 '~es ! ~ 1 i ( ~F21tP.I' ' ~'i~.~:, '~e:~rb~r:~. "i~r:+.-~n ;
d ' Ir.!r~nt Ce:+<•n
a0 I 19. CAUSE Of OEATH MEOICAL CfRTiFICqTION Q
j unse: ar.1 lle,th
~ z i I. D!SEASE OR CON01TIOh n ~1, i - a
' , ~r~:Ghed cnest wi ~ntarri3l in,,uries
t~r,e r c u.~~ DIRECTLY IEAD~N6 TO 4EATH• a--~- - - s
~ ~ ' i AN7ECEbEMT CAUSES ~ I i
y ~ • Thls da~s not mean the I MorDiC rnRditicns, II +n r, i OUE TO i h1 r~ct u red lar,rnx ~':'i ~O ~ d i
Fa H moda a1 Q~in¢. such as he~rt ~~se to the ahnre cause a statln¢ ~
!J Q laiiure, asth~nia, ttc. It jh~ undarlyin~ Caui! I~st. I ~
~ ~ f~1lin5:~FdiSlOSE.In{ury Ot ; t- I
. ccmpi~caticn xh~cn causad I ~o:l"'~~LLTl : i,OT'i:':LL'1 _t•E' ~ f 2"`~C -LL't' O_ I't , Z 8":Ll.'' g
(9 6UE TO ici
: dcath. ~
~ i II. CTNER SIGNIiICANT CONDIii0N5 t
I ConGitlorts contributin~ to the death hut not i ~
a related to t~e disa:ss or condliion causln~ daath. }~Lll TL E ~ FiC~ I"it ~~~:15 `
~y _ - ' s
V 19~. DATE Of OPERATION ~ 19~. MA10R FINOtW6S Gf OPERATtt)N j 20. AUT49SYT f
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F' 21a. ~CC~DENT ~~cPdrs~ ; 21b. PLACf OF fNlltN~ te r.. ~r ~,~o~~ ! 21e. ;CITY, VILLAGE, OR TOWliSNIP; ~COUMTYi (ST11TEi ~ a
~ $UICI~E ''~~m:~. tarm. tact~:~.c:reet, 'v~-e Dl~P...ett.l
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0. iIOMICIDE;'~~ci,~e:~t ; Sec~ion ?2 ~~iss•ir '^wp.. ^'usrolu~ ~`.ichj~~~n y
~ 11d. TIME ~~t,r!r,i ~~!ias~ ~i1'ean itiauu ~ 21~. lN1URY OGCURRED I 21f. HOMf DI~ IM1URr OCCUR7 ?
~F Krt1ie u r 1 l~ot \R~,ile ~ ~
~ IMIURY ~j_l ~~i~~ Z; 1 r I ct~,.t LJ ~t K'ort ~il ~:'ViC) CAI' :18i1'~-011 COil.isinn s
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22. I hereby csrtit~ Ihat I rtt~nded ~he deceassd from~_~?~~~1~~_J-1~~i3~l8~__~yr O~ oo ronsr, 1t~ .V, ttat I last saw th~ Mt~axr aliv~ +
~ ~ n . •
an 9_.__.. and th~t daath oaarnd ot _ __m., trom iM wosts auG on tM 4L cUUd ssor~. i
~ - - ~ - -~7-_:---- - - - - - - - -
23a. 516NATURE ~~~•=«e :F~ 23b. AODRESS ~ 21e. DATE SlGNfD i
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~iarol~i A. ^e~ierbe~r„ ^oroner j Sa~inaw, 1'•ici~i ~..z ~ 5-?~_5~ t
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Y4~. SURIAI, CREMATWN, i 24D. BAiE 2~c NAMf Of CEMEIERY QR LkEM~TORY ~ 24d. LOCATION ~~1:7. t~lli[e. twD.. ct ccuni>> t~ut~~ t
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~ ~ur~i1~. ~ ~3-- 9 ~ 0
_S _ ~ _?olY~ SeP~lchre a:~cl..~n,i ^ount:~~ ~`i~h, :
l-38 DATE REC'D BY L0~11L FEG. f~fGtSTIIAR'S SIGMATURE ~ ~ ~ 25. FUMf~1 DiRECTOR'S SICMATU~f ~ ~ °
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5-1~-~-59 ~ R v~e~et~rsen~'uneral Kome~ ~e~rborr?,'tich..
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