HomeMy WebLinkAbout2007 . ~
rorm tus-c.r~~a.uc.opot n..wG«tUoa i~11NNESOTA DE?ARTI~AENT OF HEAITM 1`~~US r
(DM~ sY~MaY~Ot t0 ~~R. l~ ~ts~) ~~~1 Sf~fWia
CERTIHCATE OF DEATH
i. couNnr ` ' sr T , s NTr' : , .
McLeod ~in~esota McLeod '
0. CIIY. YIltA6E Ot TOWNSHI~ c. lEN6TH c. CITY, Y M
S? i~lb.
Hutchinson ~rs. Hutchinso~
e. wwE oF ~~.a ~?«a+.~ e• ~n~.~.. v'~
a~ .dd.«~~ a.
nR~ ~woRCSS ~OST OFNCE
~~ma~i636 Glen St. S. 636 Glen St. S. Hutchinson, Minn.
~s MACE pf p61?~11 ~I~S~pE CpRfpR/?TE U61~ii1 IS RKIDENCE INSIOE CORIORATE liM1iS! f. IS REilOENCE ON A FARAI
Yes~ ~+o O ~res Q uo rK O~ Q!
R~ N I CHOLAS SEMON BECKER ~~°Fn, June 14a'I 964~
S. SIX COIOR OR RI?GE 7. WIRRIE~ N~?ER MARRIEO Q~. DATE Of tIRTH A6E ~1~ ~rw F UN 1 YfA IF NOER M I
ma 1 e wh i te w~oow~o 0 o~YORCC~
o Ma r. 30 , 1896 `
10~. UWAL OOCU?IITION (6iw ki~d ot.o.k tOb. KIND OF ~USINESS OR 11. ~IRTHKACE (51~M or (or~iq~ toMtry) IL CITI2EN OF WNAT ~
d°~bu
i°I'~ i n'°` c~int
ra`c'~`o~ '"°`~~~ist ruct i o~i M i nnesota lf.°~":`Y' ~
1~. fATNER'S NAl+IE 1~. IYWTMER'S MAI~EN t{/~I.IE 1{. SIOUSFS HMAE ~
Nicholas Becker Kath rn Rep~Lert Emma Bryntenson ~
IS.• WAL D[CbASEO EYER IN U. 5. ARIAED FORCBt Ib SOCUIL SEGURITY NO. 1I. tNPORW?NTS OWN 516W?TURE /10DRESS
N~:i es °i'"''~'~M~'Y~"`°~'"""~~ 554 10 6348 ame S. Be ker 1823 8th Ave. S~
cawsE OF ~EnrH o.M o.. uw~ o~? liw 10. (~1. iei. ~ad (c).) • ~ ' iNTERWLL tETNEfl1 ~
ONSET AlID DEA?M ~
~A[i 1. OfATH WA5 CAUSEO ~T: o
IM4EDIAiE GWSE I llall l t I OIl - 4 weeks N
ca.a~. ouETO~b~_carc i noma _of the r i_ght _ 1 un 2+ ears
.~~q...~~..b ~
I
z M.~ c... w oue ro l~) - - - - -
O
F ~AIT 11. OTHEt S16NIFICANT CONOIilONS CONTRI/UTtN6 TO DEATN !UT NOT RELATED TO TH~-IMAIEDIATE CAUSE 61YEN H. WAS AU10KY
IN N1tT 1(~) ?ERFORME01
~ ,res D Nwo
~ Ih. Tldi OF OIEtA• itb. M/UOR fl f ERAiI N
~
~ l0~. ACGDfNi, SUICIDE OR HO?IICIpE. {S?ECIFY~: : 2Gn OESC.RIt! HCW ~NJURY OCCURREO. (fah. wtw of i~'tYry ~n hrf 1 w?Kf 11 ot NM~ 1~.)
~
~ V
~ ~ 7~. TIME OF Ho+r rlwl~. DNr. Yw~ ~
i~uuar I
~ o. j
IWUR1f OCCURRED K/1CE OF 1li.lURY (e. q.~n or ~bort 20(. CITY, YItlA6E OR TOWNSHI~ COUNTY STATE
lIILE At Q NOT We11LE Q Aonr, t~nn, (~c1oh, str~et oiFias bldq., Nc.)
WORK ~1T WORK - - - ~
~ ~«.:f~ ~ .tt..a.d e««»a srow t une ,-~..a . °u une _
a~d 1Mt dMM occrrrod ~t (~..e~. ~
ll~~__ _ m. o~ N~s d~?~ it~t~d ~bove a~d 1o t1w bat of m~ k~o.ladq~, iw~ tlw s~wa d~Nd. ~
2L. S16NATUtE (0~9?» a tifb) ?~b.
A
C.G.Sheppard M.D. ~ Hutchinson, Minn. .
, 2l~. WR EWITION ?3b. DATE I]c. N%1ME Of CEIdETERY OR GRHA/1TORY 21d. IOC./1TION (Cifp, vilbq~ w cordll) l~~ E
REMOVAII~~h) ~ ~ d
burial_ ;June 16,196i~ Lake Arvi~lla Cemete y Dassel, Minn. t
2~ DATE FILED ~Y ~]S. RE6ISTR%1R'S316NAlUKE ~ 26. SIGNAiURE Of ~IORTIGAN OR WNERAL OIRECTOR /1DDR~- ~
IOCAI RE6.
6-16-6~___.__C~_
G• She~ard____________i_:Donald Dobratz, Hutchinson, Minn. ~
. - !
,
~tatt 0~ ~iriritgOtd, DISTRICT COUR'T'
c~ McLeod.. Fi rst i
o • ~
f-.-... . ------------------------------J~.;~:~1 ~.ss ,
- , ,
_ 1, ....1~B.S.t011_.8~.(1501'1.. _ _ Clerk of the 1)idtriet Court in and for iaid ~
Cou~ and State afaneaid, do henby eertifJ tleat the ubor:t ia a true and cmmcct copU of tlu oerti~oate f
of death of............ _N.i..cho.1 as.....Semor.l...~.ecke.r.... _ -
, on ~llt and of
o~. . I.1' T1:'.STI.~IO.r r~F'HF,ITI';OF, I have h~ru~nto a~t #
FILEO ANO RECOROED ' nii~ hand Rnd a~.ral flie sral of eaid court at
ST. LUC~E COUN?Y. FLd. ~ , ~ '
R~ ~FiEO ~ ~ ' . Glenece rKi~nesota., tleia....l_5th
! ~ . .
1 4 i . .
- ~ ~
. , .
. . ~ta o Oct b.e.r , 19............ .
b .
'69 FEB : I 6~ .
7 AM . .
~ _ . . _ . . ....Dutrcct .cou rt
, i - . Clerk of the
e0~ . i=01TR~+S
_ . . .
CIERK CIRCUIT COURT - By . . . .
~ ~ ~put~
' I
i
8aox1~5 ~~~004 ~
- ,
- - _ - :
: ~
~=t ~ _ s~.r. . _ ~ _v.~~~~~: