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.CBRTIFIED COPY OR R~CORD OF D&ATH. ~w
Fo~m by Atic4itan n~~~m~oi ot ttea~~e. 140'J a~X ~
lWrn
CERTIFICATE OF DEATH ~
saa Fi. N~. ~
MICHIGAN DEPARTMENT OF HEALTH . ~
Viroi R~cords S~ction ~
BIRTH No. Local Fil. No. ~
1. PLACE OF DEATH • 2. USUAL RESIDEN E nuc wcuiw aMw r ~nn naracc wKa ~~u
a. COUNTY ~Mw o_ STATE N b. COUNTY ~
b. CITY (r ar~rt cw~+un uwrs. ~en eut?~ ur ~nc c. LENGTH OF c. TOYrNSHIP, (iur[ o11 ~s ~won~tE w~twM urrtf Or
OR • AY (y t~ CITY OR ~C1Ttro~mooerwnT[o t ~
VILUGE ~~t • i~ VILLAGE ~ Ya ? Np ~ ~
d. iULL NAME OF (v wr r rn~TU w~smnw. c~ sran uwas M~wn~ STREET Us tue~LL. sn[ toun0ll) r
' INSTITUTION ~`j~~ AODRESS ~t`~. ~M ~
3. NAME OF o. (n~sr! b. (rioo~rJ e. (usT) 1. DATE (rorrn) wr (ruel
DErfEp\ltlNT) DEATH ~
S. SEX 6. COLOR OR RACE 7. MARR~EO, NEYER NApR~ED, 8. DATE OF BIRTH +9. AGE f~ ~ws v uro[~ ~ rue I ~F v~oE~ uH~i
I ~~~EO (secan) I ~m••~•4 r~.rn ~.n rw.s r..
100. USUAL OCCUPATION 1q~[ o~ ~r ws) 10b.~ K=M=OF BUSINE55 OR INDUSTRY 1 1. &yTM~CE
(~O! FOlEICM COYMT\~) I 12. ~TII~11 ~ wMAT COU°~4rT i
. oo~[ w~ut~•! EIIEJI li tEiltEDl A ` ~ . 3
13. FATHER'S NAME 11. MOTHER'S MAIDEN NAME 1 S. NAME OF HUSBAND OR FE OF D EASEO ~
~ ~ I ~ I ~ 1~~•/~ 4
16. WAS DECEASE~ EVER IN U. =ARrED fORCEST I 17. =1AL SECURITY N0. I 1e. INFORMANT'S NAME ADDRESS
us. ~war~) r ns. cna ~a~ K wns ~r urncv ~ ~ ~ ~~rt t ~
19. CAUSE OF DEATH ~~KAj~~~~ ~g~,~'~~ltM TE o~?n~ '
1. DISEASE OR COM~ITION ~V ~ '
' uT[e anr os[ uusc ret DIRECTLY LEADING TO DEATH ~(a) -
UNE FO~ (a). (b). ~11D (t). .
_ ANTECEDENT CAUSES a,r,~.,~.. ~ t er. s r~
~'(HIS DOES NOT MGK YO~IID CONO~iWlli V AMY. iINNG DUE TO (b~
THE MODE OF OYING. tlSE i0 TNE Aq1fE GYfE (O) S7ATNi iME :
SUCM AS HEART iAIIURE. YMOElIrINi pUSE LAST- ~t~t~~ jM~l~
~ ASTHENIA. ETC. IT MEAItS DUE TO (c) -
THE DISEASE.INIUR~ OR OTHER SIGNIFICANT CONDITIONS ~
COM~LICATION rVHICH ~pnqrS 0011TtlWi1NG TO TNE DEA7N WT MOT
CAUSED DEATH. ~uiEp Tp TME qSEASE O! COMpi1011 CAUSiNi DEA1M.
19d. DATE OF OPERATIONI 19e_ MAJOR FINDINGS OF OPERATION 20. AUTOPSYI
YES ? NO ~
21a. ACCIDENT Isrtort) I216.PLACEOFINJURY(E.i_u~o~iuarr 21a (CITY.VIWGE.ORTOWNSHIP) (COUNTY) (STATD
SUICIDE eor~ s~~r. s~crwr. sra[Er, omcc ~.cTc
HOMICIDE
21d. TIME (ro~nU (o~r) (YUe) (xouR1 I2fe. INJURY OCCURRED 21f. HOYr DID INJURY OCCUR7 '
OF wH1iE AT NOT MNILE ~
INJURY M• MORK ? AT XORK ?
22. 1 MERElr CENTIFT TMAT 1 ATTDIDED THE DEC~i * 1~ • T~ ~ ~s
THAT 1 IAST SAw TME DECEASEO AUYE ON ~ 1f _ AND 7HAT DEATN OCCURREO AT M.. .
FROY THE CAUSES AIID ON THE DATE STATED AlOYE- ~
230. SIGNATURE (ocs~[oenn~ 23b. ADDRESS 23c. DATE 516NED
[~t~ illws, dir. IIlO I'[~~ MtM I f~t~-S!
2~0_ BURIAI. CREMATION. 24b. DATE 21c. NAME OF CEMETERY OR CREMATORY 24d. LOC~TION (an. ~aucr. rn~_~c~.
) (o?~
~srcar.) I~f~ I GN~Ittti ~A rr~~ y~~ AiM!
n lKK E~. RE615TRAR'S SIGNATURE 25. FUNERAL DIRECTOR'S SIGNATURE ADDR~s_
S-i4-M I L~/w A. lMMRA~ I.MMP~ 0• ~ltN~~ It~w~ NiM~
~'rf~'rE OF 1'IIC~iIGAN, _
~ [~~f w. ir~rieM~r
COUNTY OF-------------------------- I~--------------------~--------------------------------
Clerk of said County and ' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ - - - - - _ Clerk of the Cireuit Court for said County, the same being
a Court of Record having a seal, do hereby certify that the above is a~rue rnpy of the Record of Death of
~ j~~~ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ now remaining in my office, and of the whole thereof.
, :In Testimony R'hereoj, I have hereunto set my hand and a~xed the
~ . t4~
~ seal of the Circuit Court the____________________________day of
• . . :
, : . ' ~ 19_=
SEAL - '
. . - _~h 4~,.~i- ~s+~ - - ------Clerk.
.
.
~ . . - - - ~ . - ~ FILEQ ANA 12ECQRD~b
• ~ ~ BY---------~.-C~~C1E-E-(~Llu?Y^f_L~.±----------Deputy Clerk.
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SOORII 17~ FACE ~ / ~.J ~68 ~U _ •
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C~~~K C1RCU17 COURT
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