HomeMy WebLinkAbout1715 ~
~ ~ New York State Department of Health ~-4~-~ -f'-'~~~'~ ' ~ ~
1 ORFICE OF VITAL RECORDS 1~` (
1`` W D~t. No CERTIFICATE OF DEATH x~~~O~
c. ~ to 6. ~r. by ,.yP,ho,
1. 11ACE Oi DEATM: STATE OF NE1M 1IORK ~ 2. USUAI RESIDENCE (WMh d~cws~d li~~d. If inslilvf:es: n~id~nt~ b~fon
' z c°°"n' Nas~au a STATE ~~w York
G' U b. TOWN IENGTM OF b COUNiY c. TOWN
~`n 0 ster STAr IN TOWN. Nassau 0 ster ~
r~- Y Y e~ir ae vnucE y
.t ~ o CIIY OR YIIIAGE d CI111 OR YIIIAGE h r~sid~~e~ viMi~ ih twporaN lirnih?
~ S osset 1 Yrs S osset YES p No
d NAME OF (If not in Aospitol er in~tiNtiow, 9iw s1nN oddnu w locotiow) STREET 1. IS RESiDENCE ON fAR1NT :
~ MOStITAI OR 58 Calvin Ave~ YES ~ NO ~
o~ ~MSTITUTION 58 Calvin Ave _
~ NAME OF 4. DATE (Month) (Oe7i) tYwr)
ti~ T,a
E.°.~,+~ (,'/,~+HGf' ~t IC Jame s C. Sut t i e o~TM Au ~u s t 1~ 6 ;
3. SEX b, COIOR OR RACE y. SINGtE, NlARRIfO, wioow~, i. IF MARRIED, WIDOWED OR DIVORCED, Nonw ef
Z m pIVORCEO (Sq~c~ Nviboed '
lttale W2~.te r'arr~ e~ c«,w~h b~ar~aret Thonson
6+ Q 9, DATE OF 61RTH 10. AGE (In rwn IF UNDER 1 ~EAR'If UNOER 2t HRS. 11, dIRiHILACE (Swq orlon~yn cew~try) 12. CITI2EN OF ViINAT "
" losf '.~hdor) - rM Dars + Nowa M:n. COUNTRr~
~~:ar 21 1 0 g0 ~ I~ ~ Scotland ~ LTSA
Z~~ l30. USUAi OCCU~ATION (Giw kind of we?k don~ drri~g inos~ of vrorkiny li(~, t~b. KIliD OF W5INESS OR INWSTRY :
~ ~ven if nfir~d)
p~ p ~ Clerk Grummans Air9~caft I:~c. ~
~ ~ 11, iATMER'S NM1E iA MOTt1ER'S MAIDFN NAME t
"7 n V
James Suttie Jane Brown
w '
~ e lA. WAS DKEASEO EVER IN U.S. l1RMEC FORCESi V. SpCIAI StCURITY NO. It. INfORMANTS NAME 58 AQDRF~SS
;a, ~ c M (Yn, ee. or tf res. 4iti w daM~ of Hnic~) R ~ 1 vin Av e
~ I~~-T~ I ~0 132-O1-1634 Mrs. t,:ar aret Suttie
a
j ~ O 19. CAVSE OF DEATM (Ent~r o~ly oM co~ on o lin~ • NTEd l 6 TWEEt~ `
> fART t. DEATM WAS CAUSEG dY_ • ~ CNSET ANfl DEATM t
~ z U ~ INIMEDIATE GAUSE (o) G ~r/~~~/,/~ ' ~v ~d NI~ !
y W ~ > Cend:fiew,. If ewr, ~P ~ ~/~~y :
~ a a whicA omr~ ri~~ ro DUE ?O (b) O ~_7~C~A~ '
E obw~~ inaw~dioh ~
~ ~ r~ p tOVl~ (u1. srofineJ (
N ~ ~ fM vnd«1r~ny OUE TO (d
cav~~ (os1.
d v p ?AR? tl. OTMEt SIGNti1CANT CONDITIONS C!~NTRI6UTING TO DEAil4 bUT NOT RELATED T0. M~AS AUTUf511
~ ~ ~ TO iME TERMINA1 CONDIiION CIYE?t IN r~cti ~ ?ERFORMED1
~ ~ ~ " rES p r+o
w~ e ~ 21e. ACGIOENT, SUICIDf, MOMtC10E (Sp~cH~) 2fb. OESCRILE NOW 1lUURT OCCURRED. (EnfN woM~ ef in'ryry in toA 1 er toA 11 ef irNn 19.) ;
V ~
C2 O N v la TIME OF Hew Monfh, Doy, 1'w• ~
INlURY a w~.
F ~ p. rw,
g ~ ~ ~ 11.L ~~Y QCCy~~ 21~. tIACE Of IWURY (~.p-. in a oAo~~ 21f. WMERE DID Ciy e~ town Cmw~ry Stet~
o ~c Q~ 1~Vlrif~ o~ NW WAiTi hom~, form, /octory, s~nM, sAic~ btdp.. ~h.)I tNJUIY OCCURI
Wed ul Work t~
~ ~ ~ - ~ t JK~eby certiJy that ! ett~xded th~ dec~asrd ~som ~L - .,19 to_ .Z , that ! lost saw the ~
_ ~ . r~ .
~ w dtt~uttd olivt oM . 19_~ a d t6af death ot al of ~j
~~~_~n., f?om tke tcwt.r o~rd on tl~t datt .rtattd ebor~r. ~
` y~~ ~ 110: SIG E. D~~p u t:ll~} ~h. ~DII~I~~' ~ t 2k. DATE SIGNEC
: /s
f" p ? . ( /O ts `
~ `j ? C~ 210. TCACE Of SUNIAL~ CRE/AATION OR REMOV L 4b, IOCATION {CITT~ TOW R COUNTY AND STATE) 24~DATE OF EU TAl OR CREMATION x
_ ^ ^7 5 ~ . ` -r, ~ a: Au . 1•+/67 -
' 230• 3~GNATY OE (INPERTAKER REGISTRATION NO. 236. AODRESS OF UNDERTAKER
= v~ A00291 79 8e2^Ty Hlll Rd. ByOSSBfi,~ 2~.Y.
2Sc. NMIE OF ESTAlUSHMENT REGISTRATION NO. 26e. DATE ALED 6Y IOCAI 46b. S~GNATURE~OF REGISTR/1~ ~
Bene Funeral H e Inc. C0202 _ „ ~ (,E ~.,'a~,:; .
_ ~
' ~p - -~--f
T,~,• { •«.h ~....d., . l.. . ~....a_-~.L~.~,rb-. a.+. d _.__.__.b" . ~
~4LN~ !M!9 fl~Ct?RflE9'
ST, I.UCIE COUNTY. FLA.
~7E •~~r•. ~rcr= 1('(1
a~sa~ _4~
'68 JUf. 3 PM l2:49
~
e.~:-
8~~'~ CLERK ClRCUIT COURT ;
. , ; - _
_ ~ - . T - - -
~4 ~ ~ ~.:T'-' -
~-~.:~~r-N~»~-
=