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HomeMy WebLinkAbout2406 . ~ . ~ - 15924'7 ~ . - ~!C: ~N N~fe-1 TY?~;: i:T:n Od L[vldLt" ~RlNTINv ORI~IVAL _:.~..;c~te $TAIE iiLlN~i$ sr~-~ F::e ~^zr ~UAe3iR _j ce.~.:~..~r i~ec:r.,.rs CO~Ot~iER~S C~~i?c=~ Qe~~srtw:~o.; ~::~,st~aio ,o. , . 'CATE Of DEATH ~o~ST[ICT n0 , NUUSEt _ ~ 1 ~ i!. P.ACE OF D~ATFi VS"AL RES~DfhCE !NMq OK~aafd i ad. »:.,v~r„r:on. ~~vsenc~ xrc.r j;•. ST~.E o. CO~~ir SiwTE e. ~~ytr ; ILUPtO1S ~ 5:.• C_"1~ ~'ifl'~?~'~.t3. ! ~L. LLlC?9 `'Q.',,o+.) i n j t. ~ I\S:pE cwpuro~e l.mds ond m Gdy. %~;ta3e. w lnccrpp:Qr~i To.r. II~iSipE cu~ otr l~,w~ti axl ~n .'xv City. V~lloy^e. o~ Ixo~porofed Torn _ . ' ;~i ~ ~-7; i ~ Q '~c_~;; ~io~rce , ~!d. ~ OUTSIDE cwpo+ofe lim~~t ond in e. :FhG7.+ OF F~ d ^ Ui$IpE cwpwuro ~.m~rs ond In ~e. ?enGir~ o• t-S~Dr~GE ' AT 7o.:isn;p non~ ~r~tc er ` J O rn3h~p rwme....... ?c w Ia ~ ° ' Y1 7 ~ q • ?~'ot~ tf ~ad D;i~nu No . . . . . . . . . . . . • • • • • • • • • . -~---1" a. ~ ~ Rood O;slr,cf No.. . . . . . . . . . . . . . . 7 1 .a ~b }f ~il1~tE OF FiOSPtTAI OR !1VSTtiUitON 9. Tri GF STA R'rSIDENCE nDURESS (S~.ee~ 6 No. o. Rt.O. oMi Post Of.Sc~) ~r , ~r t~ ~ . _ a S -rli?.Mba Li? ~ S ~-o~'~:_ ^ : ::L'e cab ~7?Cls L~.B ` ~I f,. I? rwe ~w nptP:tal w:nsr;r„t:on, q:ve St~eet 8 No. u R.F.O. au io~r OfF:ce i~ i~ g. D%d dececene res~de Ot+ w Fwu~.> rE5 Q n0 r~ ~i3. N~~sE OF e. (Ft[SS~ p. iu:06~E; c. ItwSt~ 4. DATE OF luO~inl (Owtrl (rf,~a; ' ~ JcC[J1SED ~..1T1'L ~ v`. ...."3 VQ~ ~ Q DEA'H Jt?."2v' 2~~ ?~J7 ~ i. S[X 6. RA~E un~~:cD !sEVER ~t~RRiED 8. 0/!TE OF B~RTH 9. AGE ;.~ra~on 'j`OdN~rew .+~~dr.2~ks. ~ - - r'3 , i.6 W~~OW T0. DiVORCED (zpec:ly) ~ :su .o.... o... ..w,.. '~•-•nl ~C~.7:7CC'E ~r_~~i~~~0~ ~J _ :Oa. USU/~L OCCUPATION IOb,KiNDOFBUStNE550R1\DUSi~tY t 9iR7HPCACE (C:tr o~d sro~e w ive;gn cam~•yj t2. G;t;:rn oi vno~ S i: ~ i = OLi::.^.'.,~1'+e =^i:l: ~~1'G?1C : _.iZl o..OL'2'1 colnfry7 ' < ~ V' JJ ~'•1ft ` ~113. ~~tTHcR'S PUIL Ia. MOTHcR'S FUIL = t~ ~rME ~tA;OEN NwME J;~ 3~~~ L~ ^.:r~x.i C~ro ~_ne Sc_<o~~-:1?;e n ~ S. ~/oi dreeosed erei :n U_ 5. A~.r.~ forces? ~6. SOC~A~ $cG;iRITY 17. IKFORv/~NT ' r' / LL(!lYe+. rw. w.r.+~wo.n~ lG;+e.ro. o. do~es d u.+:ce3i tvilMd`ck a. StGNI~TURE ' i.AUSE O i: ~ 'ii ~ ~ ~ ~i' ~Y L' ti(f'~,L :~r= 7cATH 4' I ~ ~O-.~7~-:1 ~ b. ADJBESS ::-il::E c. REL/~TIOhSht? ?O ~ OfCEASED !`:6. vED:CAt CJ~USE OF O"c/~TH )'_~i ; 'ti ~ ' ~ ~,Jl~ S: JAi: 7. OfA7M W'tS CAUS:D QY. Icntu oah ~ne :.~,,se pri ;;ne fw 1A1. tiS aud [C! l~• au ~ i! , ' iMMCD1ATE CAUSE (A) . ~ ET t~~~D~O:ATli . . / ~ j: ..........................~..--~....~c.,r=~.-~-..-..; ....~,G!i::r'- ~-~h:C-~':.r~-'.:Jt...... _ ' _ J CJ.~~~t.Ons. C'?. • ~ ' / . ~ . ~.n~:e y~.~r risr •o due lo lii / / w { ~ ~ ~ _ p i r--ov.ai~,1~1cD:ATE ~ ';i-'L:-e.c~-~.. v/~~.~ G:!.~.~.(,.4-~_I..`,~,~'.L~:~.J..J•-•..`y'U'.. .-s`~~ :~.Y z y :.~,~`sE i~~.,r,:,:~~ C - ._y~.~ 1 ~ 'rr UtiD:RlYitvv d~~ ?o (G 1 ~ GG4SO IJS'. ~ ! . ~'~PnRi t~. O'~=R SiGNIE!GANT CONDiTiONS GONTA~BU:~t<G IO cAiN SUi N07 REtw'FD SO TrrE TER?~iNwl COtrD:T~ON O. AUTOPSY? V~; v1Y~N I~t PAiT 1(A}. N ! ~ i' l9e. o.ti o? wu~*ww ' ~i9o. r.wo~was or o?u~r.w = - ~ ~ ~ ' ~ ~ ~ YiS ~ NO ~ LL p I~2ia. ACCI cta. ~ SWC' ~ ~21b.?U\CE dF IN,;U2Y!e.9..:+o.o~at 2~~.1NJUREO AT lL~~r, IOWNSMf1, OR LOCATIOYJ ;GOwvTr) (STwi~~ ( Aace.ronc_txbry.st~rri.oi^ce:.~C~.-~t:.j ~ t~ UvDETc2tittNED rr0?.t:C?.2r~~ uQ+ ('2(d.TlM.c r~..ov., ,..o.rw. ~o~n ~.a.~~ Z~e.INlURY OGG!/ddED 21f.HOY/ D10 /NJURY pCCUR7 `y iN,iURY A.M. c ~ ~ WH;L_ AT NOT'.Yti!~E m I, P_M_ wORK ~ wT w04K ' ~~t ~2a. J~:n med~col ;r.res.•~gotfon 1 fn~ eA;s dro~h .os co.:sed os srJrrd a~ore. 22b.Uponoff:c~ol:~~es~~ga+:on/6ndtAeknondesc~;:,eda~~OSitO'NOWir O~1[: f~GwtO+ ~ . OAiC: •1~Gh[O: . ~ f ~ i' Y / , /J > It ' CG70t.tR'S~ ~ y . J\TY ~ U' ~rYS.CfAti. n / ~ I ~ _ CO~CNEQ. , 7 ` ~ M. FU ERnL D ~OR ;i23. DIS?OSITi~\: 6U~1/1L•~~~%/~i~~c~f~,G~:Qti.1.Qete7..~~J.l... ~ ~.~METcRY _..r!.::~.~'G.~...<.~Y..1 SivN/1TU E '^~1.~~.~'~-~_. f; • Y uJ' .OCl~7t0\ ',7> •°rCL: : n ' o.- v_ - - - ul.. .,l,ne~s ~:eenz j - _ _ ' - ~~~~ESS . . _ - 'ri BlTY ..~l. .-._u...:.::~i _\p ;~'7~ O ' - ,1: ` 7--••... ~ - ~ - LL:N'JfS :S. Re:r,+ed Fa (Jigneof • _ j~ ;n~ ~j ~ i ` ~ i~,: ~ -BELL~1li~ ~ ~ ~ C'iCn~ R_GtSTZ/1R ~ ~ ...c „ t tl ~Ith.'BY (.ERTIFY THAT the joregoin~ ua trueond rnrrsct rnpyo/ ~ht recorrl Joi tns J~', ' n.,med at irem 3 and ~hat ~hia record waa eatablished a•.d jiled in my o((iee in accordance wilA t.~e pro:~iaiona of the ]llinois ataeutea relating i+trotion of inha, tillb' ha and deatha. "e ~ ~ CJ . . . . ~ ~v' C~ • DATE JV.I. ? ~~....SIGNED.... IG~ : r • ; = OFFICIAL TITLE - LOCAL RE TRAR ~ - .t ~ << 'i`~~ , - ~ AT BELLEVILLE, - ~ . ~ ILLINOIS BY DEPUTY..,~'~. 3 ~ Fr~EO ANO RECORoEo ST. LUC1E COUNTY. FLA. f'f:~!'F^ V~R(Fi~D '61 AI~C I 8 PH Z: 49 !t(}':'c N ''~ITR~S CIERK C1RCi1tT COURT ~xi~~' ~~~4Q~ - ~q~- , ; YT4" y~,i~ ~'~•4..:,t