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HomeMy WebLinkAbout2397 . . . _ - .L64963 OH10 DEPARTMENT OF HEALTH ~,D"`.1`j°. ~30~ DIVISION OF VITAL 3TATiSTtGS s""~~`NO' *`'~41te`~ CERTIFICATE OF DEI~TH N' OECEAfEO--NAMt H.u Mi~i/e wr f[X OATE O!' QtATM lAb~?. Db. Yrl a.!' b RqCE p~+•.••p+. ~•k« AO - t.r~ w+o[R ~ rtwa u?aee f awr piATE pi N~TM //Ilir~fi, D.~. COUNTY OF DtAtM ~ w.~, ~s. (St~~i/s1 (s~J Ywl ji. 1a~1~ s.. s?. 8 aTr, v~cuocE. oe ~ouna+ w oum IMSIDE CITY IIMITf /10~?IiAI OR OTNlt II~TIMMIi-NAME ~U••~:••~ra... s:..,....r..i...w.~ ~ ~SNci/f 1a N r~1 i n. P 1TAiE Of ~1lTN fIJ Nf i~ ~I.S.A.. r~t CITI2EN W W11AT C011MTtr W1t~~E0, NtVN MAtR1Ep, fYtV1Y1NG i/OYSE /lJ viJ1, ~wt ~~i~/r~ r~s~1 t~ 1 w~oow~. DIVOtCED /SHsi/7! • 10. 11. SOC1Al fECllltTY NtIMtE! WAS DECEAtED EvER IN U. S_ AWED fOtCEii IYa. s~. ~r ~s4rwJ fll 7y. ~N w~ N~N 1~ lf/fKfl 1~~. ~ 11b. YSYAI OCWMTION f Giv~ ~iaJ ~J wr4 /~r lrriy wsit e/ ItiMO Of WS~NEfi O~ INWfTlll ~srrliss liJe, ~?h iJ rdirrtl 1 t ~b. tESlDE?IGE-SiAiE GOYNtY C~TY, vlttAGE O~ IOCAiIOIi INSIOE pTY t1AtITi STREEi /W~ liYWEt IS~f[if> >N M NJ ~..Ohio ~.s. ~.~.P ~w. fItTNER-NAAIf Fiist A~i~IJ~ Lst MOT/1ER~tA1GEH NAAIE Fint /WYIt (.rI 1 S. Cisisr 1 INFORMANT-NAME ~ui?~NG ~oceESS rSa.n «R.F.D. w.., s:i~.r rW.`~, wa. st?J 17e. 17b. oEwni wns cwusso SYi IENTEt ONIr ONE GIJff /E~ lIN[ fOf (d. 1~1. ANO (d1 ~ . w+~a~n u?usE -L • C~ilifi~u. i/ p~. a+t TO. O! AS CANSEQUENCE ~f: . ? r~isi sr~~ ri~i e• ?1 DUE 10, Ot AS A GONSEOUENCE il~t~r~ tie ~~1sr- r~rrr !rt ~ /M1 11. OTME~ SIGNIFIGNT ~1'101TIONl:(. ~wlitioar te~triiili~s !o Jtirb irt wt rel~f~ l~ tait ~t iA ~~rf 1(~1 A1RCfS7 If YEi w~t ~/i~y s~cl/~?e1 fYer M nr /~tn~iws r~sr~ ~l J~~t? 19~. 1N. Ot UNOETEWIN D~f~ Md~ Dr~ Yesl ~R ~w INIUtY OCQIflED (6tf~r ~+frrt ipr?~ is'w1 I~? ~rrt Ll. itt~ !f/ ~a.. ~a. ~a. ~oe. IN1Ylr AT wOMC ?tACf Of INJUIY At w~. l~?s. mr~r. lia~rf. tOCAT~OH lSntr~ er R.P.D. M.. tly er ?ilbp, q~t~. ri)1 rfMs:/~ su «..1 o~r• hty., rn. rS~sd1~1 70~. C[ffIF1GT10l4- A/~~lb D YIn .Ne~tb D~j Y'tn AND l/LST SAW HIM/XER 1 OID/GID NOi ~EAtM OCGURRED A/ IiI ?/ISI ~I ?MY3ICIAN. ~ ~ p~ AIIVE OH VIEW THE WO~ IMOUl~ IM f~ft, ~ N 1 ATTEtqlp TItE s~~ ~ TO ~ ~ 8 .Nosrb D~~ Yea AiiER DEATN. ~ V I~~~I/ b 2t~. OKE/1flO ftOM ~ 11.. ' ]Ic. 2 - 71d. N(~ ~1.. M. flts~wl.,J`N f~l. CitfIqGT10N--Op~O?IfR, Os fL~ isfif t6e ~s~riuli~~ Horrr e/ 1~+t6 Tie /t«d~~/ r~s ~r~~os~crl 1~~1 ~f ~M i+ll ~~~?W i~rtsti/+w~. ii ~ qiaio~. ~~/b M~~t~ Oq Yrw H~w k~n~I es JM l~ti d Jw 1~ tM roi~il ~wrd. ' i M. 22~. CElTI/IEL~-~lY1E fT~lt.M ~?nMl . SIGNATURE Dep« w rie% OAt s~ RI(~ABD L. WAt~iER, M.D. „s_ l MAlllllG ADOtEU--Ct~ilflft SilEET O! 1.f.0. NO. GtiT O v1t F S1ATE 21/ " . , , e ~ WdAI CREMATIOM DATE HMtE Of CEJME/E~Y OR CIEMAiOtv l TIOM 1Cir~, ?ilbp, ~r o~inrsl /SINI ; ~s~~ • ~ J ~ 2M. 1N~~b~10 1 k.Pl~a~ti 9~ v~~ ]Y. ItAME Of tM~AtAlf! IUC. f". ~ ~rf~ERAI'OI O SIGNATUtE IUC. NO.) ~ Jola D311 62 ~ WlIEtAI rytM /?Ip ApplEil (Si!!Ei NO.) ~ (GTt) TATE) (II?~ t7. ~~V• ~V~ ~i ~ DA~E ~K'D ~Y fEdl ' S16NATYtE DATE ~E~/Ali ISSUED IONAiURE Of ERSON 1sfUfNp IEfMIi pifT. Mp, LOC/~ tEG. L ~o. ~ r~~~ ~ k, _ . . ~ ~ ' ~ ~ " ~ ~ . _ - ,.-;:~c•..-~ x~~;~