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HomeMy WebLinkAbout0144 ~ _ - - ~ 1QCROFILI lQ~110 _ _ Le~ibility ot writins. tjrpin~ ~ ~ . s or printins onsati~isotor~r in ~ t6is docm~ent ior ~iarofi~ains ' ~ _ _ . .__,.._--.--a-- _ - , , . . . - _ ; . . - ~ - . : ~ . _ . z= ~ , ' . ~ ~ filL 1N k /IH TYifWR11ER OR tEG1QLE IR1N?INC. ' , ' ,aQrciH~L STATE OF ILUN4IS '~t~tFF~,F . 15t58~ 1.ywfR ' N~~s~~ ~ I MEDICAL CERTIFICATE OF DEATH D~SiRICT NON NUw1~ER f0 ~ „_1~____- - - ~ ~ PtACE f?F U[ATli 2. USUAI RESiDENCF /w.K,. ow.o.~a ~...e u.,,r.r.•.oo. .~rde~cs s.~o.~ a StAIE b COUNfY a. S~A{E S. CM1NTr od~nyo~ = i~uHO~s ~ COOK Il,l.iN01S COOK u c xj 1NSId1 co~pani~ r:md~ ond C~ly. VJi~~~. « Incp.F•oraei.d i~rn c• 0.J' INSIDE co~pao~a Lm.h o~.d .n i,~ry. i'iU,r~. a l~aporeld Io.~n ~q GRANGE, 1lllNOtS U1 GRANGE. I ItINOiS d[] OUTSIDE coaporeh im:~, o+J m_._ .~tn;,'ti~ i~R StA d. [j OUTSIDf cw~~.~~ds I.,~.r~~u.~J •n - ,,.--U?ibTi1 et tE ~D ------r c+ ~!1 4 w b~ ~?,f h o~ Id - ~ IurmA~p n~ttrr~.. . . lOwnsA;p no.wr. . . ~ YEnas Ru~+d U~sf••c~ /1u. . Rood O,s»;cl No . . . . . . . . ~s i. NAME O~ HOSY~IAL l~R INS1iTU1:ON ^ 9~ IENC,~H OF S1A RESIDENCE AODRESti tS~.eat 6 No. w R F.D c~d Pos~ U~ce) ~ - 6~~ a~ CQMMUNITY NEMORIAL GENERAL ~g~'~pAYS 345 SOUTH SPRINC 1VENUE ~ .o h tt p~ is ho~p:f~l w~ns~.fu~•u~, q~.e St.ce~ S No. w R F.O. en~ Vo+t OR~ce - er+ - . e~ q.'D~d dsceden? rei~de ON A FARI.t~ YFS ~ t~~ z ~ 3. NAt~AE OF O- i{:RSI1 b. (MIOCLEI . C. lLAS11 4. DATE Of (MONiHI (OAY) (r ~I . oECC~sE~ ~pUi SE BLI SS SPRAGUE oE~jH MAY 10 i966 S S:-X D R11CE 7 MARRIED. NEVFR MARRIED. DAIE OF BIRiH Y/1CaE f~w~~ort '~'~~N~~ - - - I MAR I EII nwoRCfo (sa~c;~~) 8 16 0 r.,~..• e~.• ..or~~ r.r. ~ FEMALE WHITE - • 2 ~6 ~ J .~u ~ t0e. 1~5U/1L OCCI1PATlnil ~ tnh KIN40f8US~NESSnRtNDUS1RY 11. SIRTNVII~CE (f~~~ qR:( Unr~' W~aC~Y~ LWh~~~Yl 12 G:~~rora ~hW HOMEMAKER HOME PHILADELPMiA~ PENNSYLVANi `~':5',A. _ u ~ - _ - - - r,~j f=rR',r, (;jL~ N. MOTHER'S EUII ° ' ~:~M~ MAIDEN N/~ME d f'~ _CHARLE3_P. HORR ~ MARIE L. nLI3S _ y = LL S Woi aecn~scd e.er , N ;.:...,.i Fu..~c~ i~ SQCUL SfGURiTY 17. INfORMANT f~ AOMITTING ~ !re+. ~u. cv u~w.n~ ~Cs:~e o.r~. u••.u) iJUMBIR 'S!CNAIURE ~ ~ ' C~EItK C/~USf uZi ~O i t~ b. /?DDRE5551OI SO WI,Ll01d SPRI G ~TiONSHIP TO b~ OEATM ~ = - _ • - ~ ~e. ~.~~~~c~~ c~usc aF nF~r~: D.~ W GRANGE:I I.LINOIS • r~fO~~.EtgECORDS. ~ = ~ ~ ?ARl ~ JfA~H N'AS c:.lo~[(~ nt (t:.re, c~~~ cr~ .n.ne cv~ ..~t IA1 Il) o~M i~)-1 ~ ~ ~-.y:-'~--- - W . - (HIEEIA`NO 0 AM I 4 ~MMtD~~:c CwU•.. . ~ N . . BROt~CHOPNEUNON IA . . . . . ..0 YS... ~ - c«d~~:~.. FtL'ED AND'RECOROED; ~ ! Z~ .h.~h ~.e ~o BRONCHOGEN l C CARC I NOMA ST, l.UC1E COUNTY. FLA:', 6 MOtiTHS ~ ~ - ~n~o6owIMMEDIAT~ . ...REEORU-VF ~~~~.0 , ~ . - ; rAUSE (At..~m.~q - { i6e l1NpERlY1NG L.~.:~ ~ .Ji ~ :e~se laaf. ~ iARI 1~ OTHFR S1 I~i1fICANf CONL'~ir`7NS CONTRI{Uf~Nb T OEATH ~Ui NOT RElAiEO T(~iyE fE~(d~At CQNO~ I~ O. AUIOPSY~ N u~VEN IN ~ARi ~ jA} O ~ ~ • F ' " ji ~ ~ ~1 ~j 19\.OA1t0/Ot[R~7qM. ~?wN~ iob r~.w .~¦w..~~ or o.i~~~.~w ~ ~ 2-6-65 BRONCHOGEN I C CAftC 1 NOMA ~ES p No p~ . p J` i:r~r:l-r~ ;'~^~i~:~~- , ' NOTE: If ~n injury v~s involv~d in lhis d~~th. fhi ~~q~pi~e~r~~URT oc 21. 1 hevebp crn~hr ~Aoe 1 on~~frd ~ee d.ceenrd hu~w . t9_~~ . ro ~"'_Lb--- 1~~_ , rAot /lo~/ ~ow /A~ Jeepted oAnr~ ~ ~ LL g ~ °n- j- ¦ • ~D- nd dedIh o~uit+d oe~iO A~_. M.. /ro~ Me covses ond on ~Ae d.tM . • ~ ~ \i / ~j~ ~At! .I:tnqii t~!inSC l/j (p~~ / - - - - ~ $ianeturo ~~"-•~:j- t ~ . ~ C /--C.~~..~. _ . M.O. SeBiKd .fJ. ! . _ . _ Nu.. .ll!!_ . . . j /lddros~ t~l. ?l4c ~~L .5--•~-Cl . ' . . ! . . . . . . . . . . . . . . . . . . . . . . . _ °`:ar.~ j ~ . . :2_-. . ~.f ' y.T - . - - - ~ - _ _ i ~ ~ Z?. DiS~OSITION: ' CREMATION Dete. ~7.2.':~.. , 2~• wNERAI 11 ~ SIGNATU . . , ^ _ ~ _ ~ CEMETERY . . . OakZ'~~0 . . . . . . . . . . . . . . . . . . . • • • - - - _ _ • N~ RES . . S• s . . Gt LKerne _ : L~c~T~oN . . H3~1 ~ida, x~ ~A~•. - - - ~ . . . . . . . . . . . . . . . ~ nY . . ~°'~s~ ~ - i ~ '-+c A._~~HORlTY _ - . t; N015 Y4. Recr,. ed !o, j~'~. ' ~ S~q~d1 ~ , t.~~~ CCUN7Y DEO'T. OF, PU9L~C NEAL~ • CNKA~i~ ' .~ss C C(l'~1M JOIaN B. f~IAU.. M. O. ~r,~,y ~Y ~ ~ 6'~ G l~G?l REGISTRAR ~ - - •'S: C ~~r'-.+c - , ~ - _ ~,~;:ii?;i:l~f/~~~~ . `t~~\;! - ` t BE~HX CEI~IIr? THAT the foregoin6 is a trus and cosrecti copy of t~ ,~~0~,'~. i- tor the decedent nsmed at Ites 3 and that this record ~ras establis L~,~ ~j po. 16.0 in acco 4~d~~ 1~q,;':..: 1,, _ rrith ths loaal Ae$istrar oi Re~tstioa DistriaR ~ prp~.siona o! the Illinoia Statuttes relating to tbs n~istration oi~i;~s, z_ r; o:= ~ - ? ~~i?.~`~M,; tJ: i~~' h t ~tlllbitths aa~ deatha. ~ . n;``.°~'` ` ; ' ' rpY 1 2 1060 SIONt~D ~ ~ a~ o ' ~ ~ ; 4 . ; . ~j " . ...R i~ •'°0~:~,::`~.~~s'; " ~ OFFICUL T1TI8 S~ Q • ~4 Illinois ~ ti~.~a~,, . I,s aran~s~ • rss ~ . . . ~ . . . ~ _ - • - • . . ~ ~ K PAGE t-. . _ . _ - - . 80~ ~ . . _ ~ - ~ ,5: - _ _ . _ i 7 y - ~