Loading...
HomeMy WebLinkAbout0515 • ~ ' . ~ t ~ . . , - F ~ ~ ; . : , ~ u+i,~.. . . . _ - - . . . . , , . ~ _ ~ ~ . . - _ ~ . ' . ~ f^~ ' ~F i~ y f . . ` , . ' . m. . ~ ..+.4*l.lav , . _ . . ~ ~ . ' " . : 1! _ • t * - + _ ~ f:~ - , . CitAA•,y ~tvr a. ' t ~+F s-c tiN r=YJINiA~ . ~ . ' ~ ~ . '.L>£ F t k 4,~ ~ ~11F. hr,t~,-H~ ~ . ~ K ts !1~ - - . _ jf ~ . P ~rYrY` ~ ~ ~ Bk`tr.0.1~- 4F Y a 4L~ ST+~TcSTICS . ~T.~.F~: , ~ . ~ Z r - .~~~R~,. I' C ~l..~No. . . _ ~ . . . _ . ~ : . ~ _ R~O~tlN'M!. Mo.+ _ , - : . CERTlF1C~X7E O~' UEA""f'H ; , 1. i'L:1('E:.UF 1?E~'!'II::.. L.~"C'3I...R , _'~CE. (1F DECE1?SED: t.,; s~i~'~y.~K/.~."- ~ ` ~ , ~:r.'b:~ro~ ~'tl :or tn~t~.,?.9~ ~t-"Qe?/= ~,t~E tc.~ S!A:e. : _ ~ ,b~ Coi:nty . ' ~ •~:.~n c t;.o al ar insEtEU~ion ` ~c~ CiLj- oF lQ~rri : , CO~#iAArt6 S7'AT~ I~p.f"l~T~i~L ' ~}L~^'('~ ilt..~u + c a,;w, tmt~s. ~r~te;RlBi 1~ ~ - ~ ~:r ! t ~1 1 ~ : S ~ t t i - ~i ~ rY~w ~ : . ~ . } ~ {di 6treet No.. .~~f ~ ~'~r`~„'ti~" ~ ,~'`,~(,0. ~ti• L~~: li cf sfay: dta T:osj3i~~I or,znsti ui:cn 3 0.,~~p'"~~"~f ~ ~ ~ - ~ i~tic,4~ w1~~~r I. . . . . ~ S.~t-. . . ' . ; . . . I`: ti:.~ ~ n~n , ~ it te) tf fcre~~it:b~tt' .Y:uiP ic,na ,lri U S. ~l ? l re~'s- . . , - - - . • . ~ - - - - F~ L~. - . r~~J~',C~ E'r1~ T" ~ • 1-- S ~ _ . . - o ~ If L S L e~t~' `;i ct}r,ipl~te f ~ 3 tc 1 Sc~c ar SeGUrtty ~ =~~DIC. AL.. C~iE71~#C:#T1~.V TT- E~ 2l~. i>a3e~ofi ctea,T~ XS~~th +„/~ld~[E : da7:_ :~~i i t-t~~. Q~ Cci'1~1P~LC. ~O ~ ~ . : . ~ - ' . . ~ 5p~. . ~Il.i~f - ~ hat~r min~tc. t S. C;,t or 6~at .Singie. ~~icloa~ rns~r= ~3 t / ~ ~1. 7 hflr~5 ~ reTti3} that x aitended ff~e deres.sed from S ~ c.~~~ ( ~I~+~ ,~4 ` ~ ~ : ried. ~ dri ttrce ~~r' ; ; 14.'f/; to . ~~C`3 t _ _ 14 6~~,b! :vame of t~iu~sb/~ d or~~aifc 6 cc? A~e o£ htub~tid,r ~r ~'3f~ iha~ I.li?sf saar.~~i~~ af3~e~ ~n ~_;L/~~ 14Y..L; !'V tf aIfre ,;~Mr 3ears `~risi LhaC. ~esFh acCUrfred cr~ the d~te and haar sfaitd r Oe r~ .abpr-e. 7. Bir~'.: 3ste"af deceas~d . ~ ~ .3' f ~ . . . . , f.t n~' :n~,, Ym~ncdlaLe cause af death . - Ai;ti: ~ ears bi?t~tt~s~DayS . If- Ies; t?i$n one- tiav ~f ~.G~!I't~ ~NC`.VNC N/,¢ ~ - ~ ~ I~ ~ ~ - - ~ : + ~ ~ • •hr:~' . . m4n ,E ~ , . l I3ur to - ` , - - . ~ - ?f = - - 9. B;rthplaCt _ . - . . . {Ct2!'. t~wn. bT~ +t)): t`:a'r [ t ~r.~i~~ ~ ru _ , ~ . " . ~ ~ . .0. tis~a, _ ocrtipatlon Due tn _ G~:~ . ~ tl Indas'.r~ or bu5fr.ess , ' ' ~ ~ ` ~ , ~,~':/Q , Oiher cohditto•is t - I ~ 12. 1`AIRf . - --~Y~.•••..s„ . ~ " ~ . tlnt't~tl. ('T~•y~4.I ~ I~.~K tt n J~ ~m .r{ks d ath j~ -.y ; . 13. Bir[hptace ~~~~~~Z~w" _ ' ~i _ . ' _ - ~MYSICIi?f . ` ~ ~ ' tf~tr: i~n.r. ~vr counts - l~t~tF~ ni G~~i~nn.r: un!o? 1 ~ ~ SS9~Or ~S~R[1171~5: ~ ~ ~ ' - ~ - - . ~ ` . . . ~ ~ ~ . . ~ " Ol apcrstlans A ?~es.rctic+t~ C.:fslzcot~_v~~ ~ ~ = 14 ~Saiden .name ~ : ~4~fe1~f`_'`,`:" } _ • . QiT ~ y_ ~ ~ o~ I5. P~*:hplace . ~1 . . : - ..s~rti.lt ti. ~ - I(f::., t•rr:; ot coun~ i ? s! ~ rtr. ~ 01 8ULOp5f~ ~ tAftrL'sts - ; k "F~+'..~ '1~ a T A.~r! fi+t~r. . 16 ~ a~ In`,ermat l'sc oRn ~y nafure\T~jVQV~1,. ~~~~t,7~J1N;R,,, _ - - - - ~ b~ Addre~s;;7G~v1 "-t-~`~-~..( c~" ~ i: deRth d-y?rdue to extrrnal causes. !W fn the following: : ~ a! <~~4s~~-tiv ~b> Date t~:e~eo! / . 3 " ~'1 `a < <Prah~bip ~ 'Accident, suiclde, or i:omidde .ts~ecify) - . ~D~ Da~e o( occurreiice _ 4 • ~r~r,.-,a 1 ~ ~tt~~~'.~ 1~,,: 11,.,.I~~~~ . . . . ~ __u ~~~a,~,,,,~,~,/~ P j- ~c~ VGhcre did tn~ur} octur? ~ ~ E'.ac~s ur.a, o~ c.~maac ~ ~ ~c r. ~.,4,.~ ~~~ccrtrhi . l~:tt•r ~ ~~~A- F~;d lnjury occu: !h or s'~out honle, on farcn, 1n tnduatrial i ~:;r.ature o'..,-~ c:ai .'..,e:,.r v?ace. in pvb2tc p2ace+ ~ ~ A.^.ar~ss ~ ~ L~~~1s~~~~- ~ ~ ~ ~ ~ i~;.~:rY t~~1~7yiK~~~ , f / ' ~ , r «"h~ic a: •a} ~~t? ce; Mcans at ' i5 ~ a ~ ~ ~ „ /~A.l-{r ,e-cJ~, , ,C:-~ re( S~gr,a.• -e 4c ir~~ ;rC-~~_-{_ c.4,{,~.~--.~! . iK. D. ~l~N - - s ' ~ rr..:•.~. . ..a~: . ~ . -i; . ..r •.t_~,r. ~ ' :~:?~.'*~SS ,~i~V~'L!~ 1`r =2 ~~l S1Q'O~Y~ L1+~~~ . . t t e . ? ~ 3 \ ~ ~ ~ "t , ' ' , ~,1 + ! • ~ • ~ ~ ' ~ • i , , ~ • ? ~ t ' • ~i 1 • ti ~ , ~ .r=~' r__ ~ - w - _ `~~~r~ . ~ , ~ a ~ ~ . . . _ _ ~t