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HomeMy WebLinkAbout0333 } , . . . _ . - - . . . , . ~ - . . . ~ _ ' _~~5691 . ~ DI8?RICt OF COLQbISIA DZT11A Ol~' PIIDI.IC HEALTH ~ . CIIl?IFICATE P DEA'!H 4 5 0 5 3 ' i. sucs us~ta ~ N/1llE OP.H06P~TAL OQ 1NSTIfUTtON (Il wt w J1M~itd, Iis~ ~tnit sf~rrw) ~ VIIJISHtlt ON A~ : ~ , , . WYhit~gt00. D. , , " • UsII4L ~[DLIfC! IIAar lird. il i~utitrti~w: R~w/wn l+1M+ ~/wiriew) a STA7E ~ ~ ~ OOUIiTY ~ a CiTY. lbWN, Oll IACA110N : . V •1 ~ . ~ . ? ~ f d STRt~'l' w IS RFSiDElIC~ WSiDE l.11[1751 R ON F ~ ` ~ , -O ~1 ~ ~ YES NO ~ YES ? t~° ~ ;?t Xr~a IfA1R O? ti~t v MitlM . Iwd 4 DAOF JUMtA W~r Yer s~ r~ ) p . F • DFJ?711 ~0 ' t s a pet' S. SEX OOLOR OR ltACE raws ~snd rasto D 0. DATE OF BIRTN ~ JAiN~AvtAtyr) r ar~a ! r~,u v v~~en it aa X 11a D~ri Xwn Miw. ~ rec• 'j-~ ?i ~1~ ~ k~~~~~e .~.o... p , N...r.. D 10 - :11 • 1 ~i~h - . Yope:lY IOo. USUAL OOGUPATtON~ (Oi..li.~ w.klew. Ob. t[W OY BUSINFSS OR 11. HiR7fiPLACE . 1=. (a?I'LErt OP WHAT COUNTltY? ki iNDlJ57RY l&.r• w l~.s~*t) ~.riw/ ..ost ol ralul hH. tNw it ntirM . 5: 1~ 1~ l~o. PATHER'S VANE ~ lSb. 1lOriNlR'S 1[11IDEN NA1[E t~. ~AHE OF SVAVIVING SPOVS~ n~r:~~l~~~e~ 1~. I'f+L ISt~ ~l ~'.,t~ 1?1 , rl ti?iC~. C~v1~~~~ 1(Ya AS DDCEASED ~11ER II! V. S. ARMm F~ORCESt !6. SO(.'tA6 SDCVRM I~10. f. D~O1q~lUfT / RBLATIOYS1lIP !O bECBASJlD tiwkaow) r«, n•• w?. l.ta +essir•) ',~ev :~~j, +~~t7C1 •1~ N'riC'+3 U~t 1'r ~~It K C~ ? I~~ 10. CJlUS6 O! DEA2H tR'~te+ wh w rewe !+r low lo? wl (s)•1`• ~ xrea~,~. ~er~re~r PAAT I. DEATH WAS CAVSm B~:: `/~J~- ~raet ran war~c e plsin- IMYIDIAtE CAUSE (o~ ` V l'L~ mnnent W nli~icA ~ • rw ~it DUE TO (W ' C - • 7 i ' ~ot~ e+w~ ~L~. G : L- ' VIC ~ ~tuiy tM wra• ~ ~ ~d fG fl~/ taw+ last. ~ p~xr t~ o~nitx stcNtFtc~?i+r ~x~untot+s ~FOi umi~ ~ a~nuuru~ w~s.rr wr wrr ~cuts u*r~ ~er~y~ ~w~s ~MS»~ a.sr nr nQ 1fE3 ~ !e0 Q}•• ~ SViCIDE HO11ZC1DE R~ E OW 1NIURY OOCURRED. t8~ter Mtar • NI~/1r ~?1°Wt o/ itsw !t.) - ~j ; i ars so ~ tter. u..rs. o.r. r... :e and 1N)URY ~ w. 20~. PLACE OF IN)UAY (R ~w N AIw~ ~ ~M1~. 1~. I~rtery, ~t?wt. ~~a 6[J~.. ~ta) ,xns p K.. .Nw~ p . ~ep~i ~T ~'O~t Z~. t an..a.a e.e.~ / 6 r G l~ ~.e ti..+.... ,l? a.... L , DwO~ oeereni d /.t ea st t od 1s A~ D~N d~T 1~'~Md~~. L~a M eaw~ ~!sMA. i1Gt(AlOltt } , ~ • ` . ; l ~ C~' u. n. /S~' ~-+~cu~" -Q`~`~~1!~~. ~t 6 2Ja. BUAlAL 27b. DA7E 23c. NAIIE OF 7 OR (~iENATORY ZJd. IACATfOt1 (C~tri=l~~ a!o'~ ~~,t~_(1lf~b) t s CREMAtiON ` ' - ~ R~xo~u. 6-24-196 Roak Creek Cemete ashin ~'-D~ }4~~~ ~ j-' s ttN~ertr An~ss % `'J sep~'~aMler's 9ons o ~ ~ n°~' ' : - . ~ - . - ~ . ` - . ' ` - 1lD/AR1Cb: ~s' ' , ' ' "i : 1~ • - - ~ ' ~ „ .~A~~~-i~~'.r.'. ' •s !s~'i~ ~ i . • ~ ~ js~ " ~ T r • ' ' ' ~ ~ " ' . _ " a.~' " _i..I~~.~~~~~~ ~ . ,r~ : 1 ' ~ ~ d__ _.._._~.___)JUL 2019fi~~ ~ ~ ` Provided it bears the IM~'RF.55ED SEA~. of ~*.he DistricL oi Columbia De~ar~ment of R:blic ~ ' ` Healt:t artd shoxs no evidenee of erasures or altsrations„ it is certified ~:;at ttye aboti•e is ~ , a true ar~d correct reproduction of the oriRinal certificate filed in e Vital Stat~stics ~ Section of that Depart~ent. - ~ . . ~ ~ ~ ` ~ b~K PACf v~,, ..--r''~' e ra Giancoli ~ ~ " A ' _ : Chief, Vital SLaL:sLics Sectio:t` ~ . ~ -_;,~+s•~.,._-,~'~ . . - . _ _ . . ~ . _ ,.r..~..~r._ 3 v--.,-~a~-_ . . . . . . . ~-•~....at.~.~i~sz.~-~ . FILED ANO REC~~ED. . sT.~v~oRD VVRIFIEO`a~ 15~12y . '61 APR z~ P . : s ~ 1:~~',;~i= ~ OI~Tr - CLERK CIRCUI7 COUR? ~ t ; 1 _ ~ t ~.,K. ~lo~ /°~?,e- 33/ ~~..~~y~.~~~ _ _ ~fi~' Y„~