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Form Na VS IS-li ;60-IOSM
WISCONSIN STATE BOARD OF HEALTH 1s5653
• State Bireh No. CERTIFICA7'E OF DBATd ~~~~r•s No. :
~
' 1. TFI L AL E( G•ed. intitutior ate ) ;
a COUNTT a STATE b. COI~j~ ;
yjaae~airi a~ru~i~ ~
~ (
b. qTT. TOMN. OR LOCATION f e. IS rL.AC6 OF D~TH ~ TFS~ ~ a C7TT. T0~1. Ot LOG710N d IS RESIDENCE Tf~7 6i
I TOwN LIMITSI~ NO ? ~ T~O
UMITSt ~ NO O i
d. HOSMT~I. OR I a L~iC.TH OF e STREET (If re~l. P!~ ~eL ddes)- L F~ARMf DF7iCE ON A
~ (If ad 'u ~a~phl. P~ ~mt ~ddre~) STAT 1~ ADDRE55 . ~
~ ~ ~ • ~ES O NO ~ 3
oN
~ ~ 3_ NAME OF a IPntl h 111iddk) . e. (Irtl : ATE • (1ioN~) (D,1) (Ysr)
E DECEASED I ~
~ iT~t~ Q Priat) A~:~ DEATH ~
~ S. SEI C~O[ OR tA ~ 7. MARRIED~ NEYER MAtR1ED O~ t. DATE OF {IRTH I f. A~_
ll~ ~an I M~~ I Haun I M~
~ M~d~7)
~ I~~ ~noo~eu a avoRCeo o j~
N ik usau. cecur~na+ ~c~.e t~a d.~ 1K. [IND OF a1151NFS5 OR 1NDIiSTRT 11. ~IRTHM.ACE 15ta1c ar (orei~n oou~trT) I IL CITIZFl~I~ AT
~ y a dax d»n~ aott ef ratka~ lit4 e~ts iE eetind) I I ~ ~ COUI~fTRT
w~,'~ 3 1~ NANE wr ` I~~ MAIDEN N11ME +~~r~*
N IS. wAS DECEASED E IN U. S. ARMEO FORCfS! li. SOCIAL SECURtT~ NO_ 11. IItfORMANT ( ~
. (Ya. w or r~kear~)I (lt 7s. ~r ar d~ts d ~arite) ! I
+ ~ ~
p ~ ~ J 1 TH od~ ore cawe Da liee t a. ) k. ~0[~LSET AND DEATH
r J ~AiT 1. DEATH wA5 CAIISED ~T:
~ ~j i < IMMEDIATE GIlSE !a)
J ~ ; M
~ • r1 :
} = ; Coaac~., r a.r. Due Ta (e~
U n ~~i!? pre r! to
c.~.
- u~ ..a~nr-
~ < ~p~,.~~.c. uuE ro c~i -
~ ~ART 11. OTHf1 S1GNIFICANT CONDITIOIVS COM~I~UTING TO DEATH tUT NOT RELATED TO THE TEIIMINAL DISEASE CONDITION tf. wA5 AUTOtST
~ GIYF1i IN ~ART 1(~) ff~FOIME
TES O NO
~ tw. ACdDf1QT SUIC~DE HONIODE IM. DFSCRISE NON WAI~f OCCURRED. (Erter ~tare d ujay ~o Par! ! or Put II a[ ite~ Ill
~ O O ? ~
~ J l~Ic. TIME OF Hoor. Maot4 Ds~. Yw ~
~ INJURf a a I
~ < , R ~ ;
U `
tN. INJURT OCCUR~ED t~a. KACE OF INJURT (n u v abwt 6omc. !M. QTT, TOwN, Ol LOCATION CWNTT STATE ~
~ wH1LE AT NOT *FIILE I far~ taetaq. Nreet, oia Eid~-. ete.) I ~
~ ~Ot[ O AT wOl[ O
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21. I atteeded t4 daonied troa_ - ud lad bo ~lire o~ -
~ Deu? oaYned ~t o~ tie d~te wted a6ore: a~d b t~s bst d a1 kw~iedsq Go~ t4 ua~e~ rtated.
~ tL_ SIGN11T1~6 w tiNt) I t!k ~DD~ESS , (!2c ~A7E 31
lIAME CEMET A ( . teo w awW) ( )
~ IEY~AL (8p~e4) I ~ ~ ~ I ~
!U AND A ~ . ~ t
D1TE ~ ~ ~
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