Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
Home
My WebLink
About
1141
1lIt~lOiFllai I~ID Ywsib~litT of v~ritin~• .t7Pipi or priatin~ ansati~isotorr io this doom~nt ~or ~ierofi~,win~_ - . . " . . . . _ _ - , ~ 159:229 ~ • - ~1~ut\RTM~fiI 'J~ DIS?AIGT O~ COLVMBU DEPAA?ME~'!' O C HEl1L?H ~ . ;,t;~ L~.`n~ TFt J.r n 1 Y`,~ , j;~ CEItTIFiCATE OF D I71 5 J~ 0 i. rsitcs o~ , _ ~ ~,•t ? NJWE OF }i0SPf1'AL OR Il1571TUTiON (1 iw A~it~ ~ +tn~t ~lirwr) ~ w 10 . ~ - ~ w~~o~. a. t~~ ! , ~ , . ~ s ' , - 1. osvJtl. ~Lfcs wiA... 1«..u+ Ji.~e+l. I in.tiedi..: nai+.... .s~irw~t . c. 5'SATE D~ OOVNTI' e. CfTY. TOWN. OR LOCA710N ~ - ,n.c ~ ~t~ ~H..,. r~~? ' - d. S7~E~1' ADDRESS LS REStDENCE INSIDE Q!Y LI)d175t IS RE5lDENCE ON A FAAIrIt ~ :t. ~i ~ I - /Y7 H S /ti/, y~.. ~s ~ ~+o ~ ~ D ~O ' . 3. 11A*IE OF P:.B dfirlle Iwat 4 D~ XmetA Aar Yeor DZCEASED cr,~ o, p;,~, e~ u~ L~ n~?~tt 7-' I-/"~(E % ~'r.r. S. SEX 6_ COLOR OR RACE 1. yasuv ana Y?u~w 1"J S. DATE O'f 9' ~ bstA~qr) n v.tw 1 tua n vxw !4 saa. ' = ~ .~.o,~. D O ~ f . ~ - . ' x..r,?. n.,, n~ ar.: • - _,.Y 100. USUAL OCCUP/lTlON SCies kiwi o/ ror4l~we IOb. [iYO Of B:)SINESS OR 1l. 81R7'NPIJIGE IZ- CC~N OF WHAT OOVN?RYT dvr~:9 wo,t oJ wskiw~ l~l~. ~atw i) refirrc~ INDi1STRY (dhfi ~r /onip? ill) . 'i~ . 'C' ~ ' ~ C~ ~1 p • 13a. FA?H~i'S I`J4'i[E 1~. Dt07Hf~tCS 1[AiDEN !1 14. NA!/E OF SURV VIHG SFOUSE ' <=.c~~ . 15. wA5~DEC£1lSED EVER IN U. S. J1R1[ED 1& SOQlIL SDCVRlTY N0. 17. bRO~E1tA1tT RBLATION6AIP TO ABCBASJlD ~ ~.~K/ LfJ k~ )NU re+. rn ~-tp ~j «rwaj A . 1 Z- " G TA L - 18_ C![USE OF DEA17t (Bwter eal~ o~e cam p{i*c JK (b): wi (~)•1 ~rm*~u. ~tc.~t , PAAT L DEATH WAS CAUSID HY: ~ '7~-- oxssr aan wrs _i:s I.titl~/IDIl?ffi CAUSE t~ V~~-~'-+-C~. CS'~"""`"'~`ti: _a2 ~ ~ ? , • Coaditiw~r, iJ ~ay, DUE 1'O (b) , uLicA /ase s~se ta ~ v ~ I abors n~u. ' ' statu* fke awder- D~ ~ " If !'l~eq carst 1e~t. ~ ~ A ~ P11Fi~OTilEfi SIGAIFtCAN! COND1T102173 cavn~H,m.ro to suru ~~~r ~m Ruto rs tas inv~.r~. ~osxMt~ox tx ruT i(~ ~ o ` m wus r`_ ' 1-~ ~ T, ~ ~U ~ r 4.: -c.'~ 20a A~C:DENi SUtCIOE HOM[QDE 2Cb. DESCRIBE HOW INjURY QO(.'UARID. (B~tes wttrn oj i~i+~M ~i /~J ~ ` i ~ io y; ~ ~ - C-~ p - . i ~ ~ ? O ...,o , , a . ~ V .Sl wr wt , , ev = j ~ i i;iJ:TRY e. *w. n ! ~ W a.... X7 t 2id. It~JUP.7 OCCURRFD 100. PLACE OF IIQNRY (e. iw «~6wt Aows. 20R C1'fY.'DOWN. OR LOCAT10P1 O~, ~ I~+~. /rtw7. oJice bld/.. da) C~ ~ m ~ 6-N~L[ IT ~ fMKt ~ . . ~ ' R~~R ~T ~77~~ ~ ! 2t. t on.na.e a.e.s..e !ro. J. . ~C / r - a • L e~a last .s.. ds.. on . ~ . r • D~aib oeNrred a1 s ea ~~-dab s1aNd ~bo~: a~d b 1~ b~at Ot 1iK k~~4~. 1?oa tlu ca~uM siat~d. ~ 22a S1GR TURE ~ ^ . ~b. 1lDDRFS3 - _ ~.a. DATE SIGNED ' . ~a~~..~af.ti. 1[. D. ~ ~u.w~.~ • Z 2. ~ , j 23tr. eUR'J.L ~:D. Dk7'E ~3t. N Of CEYE7ERY OA CRElIJ~7'~Y IACATION (C:tl, to~ew, orcoawtr) (.ttate) . ~~,\,,,~,_F~'~aT' J~ _ ~ ~ I ~ :r'. ' . . ~ . : ~ ~ J f..w~ ~~G _ r s ~-_a - . f~+. YU.+:Sii.i h,.+...-+ ~ - S{G ATURE 25. liNil ASfA'S / w ADGISTRATION ~ + Ar.r~F~~ ~ ~ a ~i~f"' KJ - ~ IYUMBER . ~ ~ '`'~j~rrr~~~'1Kr':~. ' . i P.EN.AP.KS: ~~~~..~.~.~~.+I~ii~'~ . ~ ± - - - - _ . . ~ l ~ J ~ ( ..t; J s t,/ ? ~ ~ ~ s-~~~ ~ • T- ~ . ~ S l . - . • ' ~ x~~. ~ ir~: . ~ { .t~ ~ . t ' ~ ~ S a>~'.'a~i~~~. . . ~ ~ _ ' . '+~4~r? ~ ' r ` f . ~ - - : - ,-~h ?t', 1~G? s,_ .N ~ -1~' F.:~?SE;~` S~L" . - - - . . _ . ~ - ~ , , _.W~~~~;. . ~ . _-,~sr.,9-~+~~r.+'-~•,-.. ~y~ . ~s~e . c~ s..__--'~ it• j f.it~? the a?~,-.:~e is ~~~~r~~ ~~{1 correcS~ rF~?~Yrd~c ~ ion . ~ertiii~a~_e fil.~c~~-~~fi"~`.'.'~~~~I~r~l ~;c~corc?s L'n~_;- of ~ ~c: .oi ~:o:.~~'~~3 I;c~i:;32•t~~~~*~_e~ ',:~'~~_~:c I.~_v3.#:t , • ~ __w i; . ~j ' . `f _ f~ . - 1~l3:'?~ ~ i.:i~is r~ ~ - - - - , - , . - ' f"""" d~i~~ ~i~ :J ~ i ct• I+..i~`c:.. . r:ll C'f i0i t'" ` R F~i.~E ~c3 •'~r; 1 c ~+r ` , . , t, . _ _s<.= . _ _ _ . - j ~ _ - - , ~ ,