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~,'°ERTIFICATE OF ~DEATH ;
:
1 Iv~CHIGAN DEPARTMENT OF HEALTH
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8, N4V ZS N~~ ~ v~ ~ s.~ ,
BIRTH No. L«al fll. No C-~ 93
1. rU1CE OF DE11TM 2. YSUAL RESIDENCE (wai wcws ~ws. ~~snnin~s ~ssa ww ~w~r1 ~
rourm ~ a p01TRA
Y COUR7 `~~rE Michi att shfaWassee ~
k tITY tw~tt ~ra+~. wn ww u~ wa c. IENGTN OF CITY~i'• (wK ~ 1s tr~s ~eNw tartf M '
oR " a""`~ ww~ Pairf ield
vi~u?oc Carson City ~ '~~"iy ~ • a ? ¦o ~
d. FULL NAME OF ~w ~~wta M rtefww. ~ s~un +wws w ucan~J STREET (1~ ~11~AL tIr[ l0~?npl) :
uHOisT~iTUiro°~i Caraot? City Hos ital 8212 Vincent Rd., glsie Mich. t
NAME OF e. (nast) (weoli) e. (usr) 1. DJ1TE (raeM) (Mi) (~rud L
DECEASEO ~
cT.r~o...~~ Archie Byron C bell u~?TH July 21 1967
S. SEl( i. Cp1,OR OA RACE 7. MAR~1E0. NEVER MAR~t[O. DATE OF OIRYM AGE • Mw[r f trA~ w rwct tr Nea ~
Mele Wh~te l~a~rlc~ie~~tco cusan) A. 26 1893 "n ..a
E OMi
f 0e. USUAL OCCUPATION (ar~ ar r w~ 1 Ob. K1M0 OF 011S~N[s~ 011 (N01itTltr i t. OIRTNKACE (st?t[otlO~O~NCOMtnl 1 t• QT1201 OF ~t1AT C0INITIt~t
~ w~rc Mn r w~ss ur~. aro w un~W ~.j
Sn ineer A am M h a U.S A. r
1~. FATHER'S NAME 11. MOTKER'S MAIDEM NAME 1S. NAMEOFHUSBANOOR MIFEOf DECfASEO ~
Jamea B. Campbell Myrtle R£ce Lida Csmpbell
1 E. wAi DECEASEO EV[R IM U. S. ARYEO F011CEt1 17. SOCIAt SEtu111YY NO. lt. INFORMANTS NAME A~~
n''~"` no °''`""`~`M"'~` 364-03-9068 Mra. Lida bell R1~t2 Bleie Mich. _
t f. CAUSE OF DEATM ~~Al CER?IiiCAT10N ~w~ :
1. OISEASE OR CORO1TIOtl w~
a~c.o.~r o.~ w~c ru DINEC7LY LEADING YO OE/1TH ~(a~ circulatory collapae
wc ~oe (e~. N~ ue cs). i:
~nrECEO~r u?usES congestive heart failure ~ s
wau~o oowomo~s. s iun. a.aw ouc To 11) s
T~sro~oc ~
T ori~ esc ro rnc iuo.c cMnc ta) a~~ n~c ~
SIICl1 AS NGRT IAfIYRE. ~ ~i. • (
.:~+na~. ~rc. ~ MuMS ouE m~~~ chronic arterioscleroaie
T11E OISEASE.INJURY OR OTMpt ~~IFIGNT CONDITION ~
COM/IICATIOM •MiCN apMp~p~ }p 1N[ Of111N MR Iq? '
G1{ffEp OEAiN. ~EIATtD TO M pfNlE Of C0 110 111 0 11 CMl9M OEAM ~ i
1l~. DATE OF OTERIITION if~. MAJOR FINDINGf OF OrERAT10N A~Y~ 1
,?a D ~ C~
21e.ACCIDENT (sRan) 216.PLACEOFfNJURY(E.s_wo~~so~r 21c.(tITY.YfLLAGE.ORTOwNSlil~ (COLIfTIn (STATEI
SUIC) DE 1 NoOL ~Aw. tAtTOlT. sT~E[r. oiflCC KYS..ETt ;
HOMICIDE ~
21A. TIME (rorrn) (e~T) trr~V (roY~~ 21~• INJURY OCCURRED 2//. HON DIO INJURY OCCURt
OF y, ~rp`RK T ? ~ wORK ? '
INJURY
22. 1 ME11E~ CEIITIiY TNAT 1 ATTENDEp TNE DECEAfED E~IL NOV . 4 „ 60 .7LI~.Y 21 tf 67
DE R
TNAT 1 LAtT tAt iME DECEASEO ALlK Or Jlll;[,~_. H~~ Al1O TNAT DEATN OCCYRREO AT (1: (1(1 P_ r
FRpM TN[ CAUiEf AMO ON TNE OATE fTAT[[p A~OYE.
! 23e. SIGNATURE locs~cE oe nrW 2~6. ADDRES3 2le. DATE SIGNED
~ H. ~R. Poff DO l Aahley, Mich. I July 24, 19b7
~ 21a. BURIAL. CREMATION. 2~b. OATE 2Ac. NAME OF CEMETERY OR CRElU1TORY 24d. IACAT1oN (an. w~+a. ~s. M own~) (~nnnD
REMOVAL (~1 ` ,
I 7-25-1967 1 Balcom I Ionia Countv, Michis[a~
~~p~~ REGISTRAR'S SIGNATURE !a. FIlNERAL DIRECTOR'S 516NATURE AODRESi
7-26-67 I Nyle B. Srskin glmer L. Dean Blsie. Mich.
STATE OF 1~ZICHI(~-AN. _
,
ss. '
CovH'rv o~_ t"1°ntcalm I Nqle B. Srakin ~
~
Clerk of said County and' _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ Clerk of the Circuit Court for said County, the same bang ;
a Court of Record having s seal, do hereby certify tbat the above ia a true copy of the Record of Death od
Archie B~rron_Cam~bell _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ oow remaining in my o~ce, and of the whok tLercwf. ~
In Teattnaony Whereof, I have henunto set my hsnd sad aff~ed the ;
. ~;~~i~? p~:,-. seal of the Circuit Conrt the------- 26th----------------dsp of
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~ ~L' ~ f ' Jul~?------------_19_ 67_
~~_w~ ~
~ - ° : Nyla B. Brskin _Ckrk.
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~ + ' •i BY- - - - --~=F~ - - - - - - - - IkPutr Clak. ~
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