HomeMy WebLinkAbout2575 ~.v~~a~a.~.aa~,Va ~7i/1aG YGCr~t~~R~~.~~• y~
Publie Health Stati~ties Seetioa--H~rtEord. C~wwtetieut U.3.!?. ~
Csrtificate of D~aath 153185
r 1. hna a Du?Ta: 1~) Stat~ ot Coa~ectieYt Vsus~ Rrs~o~cxa e~ Doos~?sa: S~aa C~~
6~ IN CamUr le) 'ldws (b1 Couab (el 'IMr~ (di I~ Re~idewee Issi~e
" ~ Cit~ or Baa,R? Uwlla~t
Hertford HertPord Hartford HertPord
~ ~ i N~a~e K 1lavje~l or t~utitutlon le1 S~net NumDsr Ye~ ~ No ~
~ = y ~1~~~'s ~ Ao~pital K iastiWtfow tit~ &net t~a llt rural, ~ir~ beatiow) It Ye~, w~a~t Ciyr er
" x
~ St Freaais Hos itel 71 A~Yebster Street
~ ~ a
O .i. 7. N~M~ M - IYie~t~ 1~1i'ddl~~ 11.~tt) 1. aeC'IAL $iCU111TY NYM~p 1
~ ,~n~~~+Aa John F Gravicer 046 05 4970 ~
a g~ Meorcaa ERTIF A t t rr. K~i+~e)
F. ~ ~ tERSONAL AHD sTATlSTICAL PAi~YICULARS tt. C~vn or Dr~n~ [Enter wy ose c~we aer !es f~)f?1 ouu~fell ~
~
z` u i. Ssi R a~ci 1. 1l.?~~y~y Nmt 1f~w~o ~xnars~
--y 0 p'AR 1. Dt4TN 1MA~ C,AV~ SYi
~ ~18 I W1~1te WWOMiO Q ~p~ ~ I11MtNA7~ CAYit ~ 01+i[TwuN~
~ C<.~C~s. ~t~•~•G Stff..•ris s eptrw
~ x v I? 1(4uaR W~sowe~ oa Dtro~ctsr om Hwwsx NsNS o? Y ~
w ~ ( w~ H~...K. ~:erie Diorio ~M~~,~.... y.~.~ ~i?~x i
b I f. Dw~s M (Mauti) (Duy) <Ysu) Dtis to 11) '
= o r ~ Jenuer y 1 1967 ~rc~'.
~s C i~~~.,./..,?y i. s
_ ~ e 10. A?R Of BtRtl~ A~1N~~') il YndeT 1 7K~ i~ uedet 1 d~~ a~~
YooW Ds» HoYn Mins. (a). ~twtla~
( ~ a J 9 g3 ' 8~ ! ~ ~ ~ Dvs to ~a/
s
~ K~ Il. Btsi~lu?a lCiqr or b~e) (Sl~t! Of t0?l1s11 tOYAtf7)
~ Z ~ PART II OTNtR SIONI/ICANT CONNITN+Ni COMTU~UTINC :j, ~~s
Meriden Ci0Ytt1e0'Ci~OLlti ro Duiw ~ur Mes RY1.wTt0 TO TN~ 7~t1lIMAL D~7tA A~~
Z+°~ tt. t~) Usu~~ Oocvrwrqx (Girc kind o[ ~.ork doue durin= mo~t at ~NMiIyN G11ILN t?1 PARi I~~~. p~~t
a<< Stl ervisor ~ir• ic Kuna~ Yd pH• (g
` P =i. SY~:tit Rf1i~Alri fb COKOi!lOlt~ Ri~O~?p IM ITpt 22. ~
w~~ (?1 Ixwtrstr os Huttxtss I~) Na~t o[ olmtio~ f?1 Dal~ Kr[~raN/,
~ y E Aetne ns. ompeny (
a~ ti. (~l tY~ Dsa~?us ~ vsrn~Kt Ya ee ?t e '
Y ~ 1? 1 T~HS or iN~«r
V v> I! ri. ~irr ~rar rov ~ • fi. fa) AtetcsHt Suxtos Hor~tue~ Nw Xwet~. ~rr. ~'Ns
..~j q s ~1ntt er Ssip ~ • r~"'V ? ?
iw.
~0
O ~ 1~. NAM[ c r
e y c e (!1 IMJY~Y OCCVYW Idl PI.ACt M INJYRY (~.p.. if~ N~N~
H H lCiUr or tows) (State or Mrei=~ eenwsr~) W6{k ~t Not WMiI~ /a~ 1~~• ~tr~~~. y~~y ~p,1
3 + w Ij. Bt aT neuts Auatri8:: Iiungery v?oA~ ~ at Work
~ ~ ~I IR Nwx~ ~erp Anthon~r ~~i ptr. Torw. o~ LocaraK Covxrr S~~rs
j~~ ~ I lCiq? or tows) (State or loreis~ eoY~tr~r1
,'2.' `o -
' ~ ~ 17. B~aTUrucs Austria ~1,u1g9~ ftl Dcscauc aor INivRr Oocoaw. -
Q r F lSwtn ~atan ~1 iwjrry iw Ptrt !
. fi 7L tx?oeN~xr's AI~HS e? Part !1 sJ it•w !t.)
a`~ ~SI'S John F Greyeer !i. I HEREBY CERTIFY, Wt I~qe~d tbe ~~ceua~ t~
•
y ~
» ~L w J~+-e ~ is~ 1
~ 11. B01qA1w C~~~j Ihte f~ja- d----~~-~' Z 4' KQi
~ 3~ ra ~ ~ Sae~e Keart wt i u~ aK~.K...n.~.~:~.~~~ .s~
; r~.K Dieriden Connecticut ..a ~~w ~...Li~- ~ o,
E ~ 20. N~MS o? Exu?~.MCa n So~r w~s E~uu.wco Lieew oaa?Da January I~ 19v7~ : ati . 3;35/~ s.
s~ Elmer F Sahvrelm i 100 H
' ~ ~ ~ Id:D• ' . ; : .
~ ~ I i1. S~x~suRS or LtftNL[e EM~wL71sa w Lc~~rsq.F~~~ ~y~' ~ .
w Thomes F FeTle Ino ~,~c: 0 armingto ~^-A~?~~e'',~,.+ ~.2,1967. .
86 ebater St ~iartford, Conn ~a..~,
?Hl$ CERTITICA?S R~ 8 R I ~ ~ ~ ~ ajiu ' -
~~7 1 sr ~ ; . - -
t•uRK vs.~ ; ; • -
- . - - - - - . - ` ' :4. f '~t' f . . . .._._~i'aT'
1 j
,~S $ A ~
-
I c~~rtify t thie is a e oopy of the certificate as recorded in this office
attest: - :.ss't Registrar of Vita1 Statistice
~.ted / L City of EARTFORD, CONNFxTICQl`
NOT GOOD WITfIGliT SEAL OF TIiE H1iRTFORD HFd?LTH DEPARTi~~T ~
~
~
. . ~ ~
FILEU AMD RECORDED
ST. LUCIE COUNTY. FLA.
=EC~r~.D YERIFtEO
- , :,1s318S .
sT : 3 a~ 4~
~n,
'-c1.:: ~ ~~Q!
CLERK ClRCUlT COURT
a~oK164 ~A~25 ~2
: . -
, ~ ~ - -
~ ~~'1 ~ ~-a,~~: < 'Y`>