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~ OHIO DEPARTMENT OF HEALTH
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R"• Di"' NO• DIViS1~N •F VITAL STATISTICS
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Primary Rts. Di CERTIFICATE OF DEATH ' Resrutar a No.
!~"i?-'~ DECEASED-NAME Firt1 ~' Aliddit La SEX ~ DF-TE OF D~A~~~ A+-eb, Dry, Ytr-1
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" b, Arr, COU OFD A7H
G [rte UNDER 1 YEAR UNDER 1 DAY OAtE OF {IRTH fMewt
RACE /bite, wesre, rtlwnka ~-,
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oiI ,. Dnt ern :14w.
iw/i.tr, ttt. IS- tiff) f
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CITY, VI~E,pR LOCATIOtN Of DEATH 1 JOE CITY IIMITS MOSfIT OTHER INSTIvTUTION--(VAAIE (1J wo titbt-, iiss rtrttt rrd wrabtr-
Nn fn er we1
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STATE OF'11RTN (// wst is U.S.A., f. dTIZEN OF WHA COUNTRY MAtt1fD, NEVER MARRIED, S~tVIVING SPOUSE // trijt, sisr wridrr wrrttl
WIDOWED
OIVOlCfD (SlttiJfl
,
torwtryl /~ /
(j/ ,
~ tst to. Ttarried tt. ~T W
B
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.
SOCIAI SECURITY NUMBER WAS DECEASED EVER iN U. S. ARMED fORCESt
lYtt. ws, er rwtwovtl NJ rte, sirr >ro er deft, s/ ttn~ire-
-
USUAI tESIDENCE - tom. Nc
12e. ~ 71i~1o-~3I+7
wr1ERE DECEASED
I ~ v ED
1 F pEA1H USUAL OCCU-ATION IGirtbisdeJwrlelowtdrriwsaetto/ KIND OF WSINESS OR INDUSTRY
.
OCCURRED IN rrortiws (iJt, tetw iJ rnirdl
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6'esterville rairV
itiSTITUTIDN, GIVE .
1]a. ~
GESiDENCE BEFORE
A D W ~ SSION. RESIDENCE--STATE COUNTY dTY, VILLAGE OR IOCATION INSIDE diY IIMITS STREET AND NUMBER .
(Spttilf yet e- NJ
,,,. Ohio „b_ M'ranklin tat, t'olumbus t.e. ves ta..2E0~~ f'edarr i~vp.
- FATHER-~tAME Fiat Alidd/t Lat MOTMEt-MAIDEN NAME Fi-rf .Slidd/t lyre
Estrer DBTASOn
J~lfred Woodruff • . ,6
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INFORMANT-NAME MAILING ADDRESS ISt-ett or R.F.D. wo., tier er eiflrst, ,rate, :ipl
?~99 Ontario ct. Colur.:bus Ohio
~TUne {~loodruff „6
r'rs
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.
1ART 1. DEATH WAS CA~ISED BYs (ENTER ONLY ONE CAUSE -ER LINE fOt (a, (61, AHD (c/1 AntoxIMATE INTERVAL
N ET AND EATH
~ETWEEN
L Q
~
W IMMEDIATE CAUSE t
DUE AS A ~S ENCE OF: •
Cowditiert, iJ ewr, ~
~ ~
S
~~~
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~ f E .
vbirb sere rite to (6 s'~ r
~ isatdint rerte fe), OUE ~~ OR ~ A CONSEQUENCE OF:
tbtiws the rwdn-
Z
_ tries rewtt Lett t
OTHER SIGNIFICANT CONOtiIONS.{osdi/iowt tonribrtirs to dtrtb brt woe related to tewtt jistw iw pest E /e- AUTOrSY If YES rrtrr pwdiwsr corridrrrd
FART 11
I . .
(Yet or we iw dttosirirs trrrt of drrtb
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19e. 196.
~
S ACCIDENT, SUICIDE, HOMIdDE DATE OF INJURY YOUR HOW INJURY OCCURRED (Enter wetrrt of iwjrsr iw pnt I o- pyre ll. itta )1(I
Ot UNDETEtMINED ISperiJrl f111owtb, Der, Yes)
~
~ 20e ~. 20c. 20d.
INJURY AT WORK tIACE OF INJURY At home, /era, thtet, Jittery, LOCATION (Street er R.F.D. wo., ritr er -iflest, matt, :ipl
I~J IS~rri/r fat er woI eQict beds., ter. fSpeti/rJ .
T
t- 20e. ?01.
CERi1FICATION- Mow/b Der Yen Mowtb Daf Ytrr AND (AST SAW HIM/HEt 1 Dt0/DID NOT D tH CURBED Af the pare, ow
tbt date,
ewd, to
ALIVE ON VIEW THE BODY (HOUR)
n
.
IHTSICIAN:
t AlTENOED THE TO ~// .Nowtb Der Ytet AFTER DEATH. / ~ ~0 r ~r t b t b t r t o / a f
1r~
:Feouitdst. dwt to
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d
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fos~
t rartt/t1 ttrtr
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21c.
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21a. DECEASED FROM ~ 21d. 21e. t
CERTIFtCAiION-CORONER: Ow tbt brtb of the e~uairetiow Her- of d~rtb Tbt dettdtwt ern p-owowttd derd - -
death ATowtb Dry !'ta /Iota
ow
a
i
i
i
i
s r ,
w aerytr op
t
sat
ew,
wrdt
o/ the bslr erd/or tbt
ortrrrtd ow the date ewd drt to the ratrrt(il elated.
220. M. 226. M.
CERTIFIEt--NAME (7~rlt o- pr+wtl , SIGNATURE ~ - esree or ~if~en DATE~SIGNEq
MAlll RESS--CERiIF~ ~ ,STREET OR R.F.D. %. CITY OR Vltl GE ~ STATE hlr
t
' 23A.
WRIAI, CREMATION DATE NAM OF CEMETERY OR CREMATORY T _ _ (City, ri(Irst, or torwt~I fSmtrl
7- -lab 21c. Forest T.a (' >" t a. '
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_urial :.b
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NAME Of EMBALMER (LIC. NO.T FUN !E a;. .~ ~.~: 1 N
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as. herald R. Y=nouff mil 2
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FUNERAL fIRM AND ADDRESS ISTtEET NO.) ~ + - :" 121ry
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putherford al n - ~• ' ~ '` ~~ " "
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DAZE RECD BY REGIST D E IERMIT I ED- .r - _lE~.Nti DIST. NO.
_s ark, ..z ~ r. i ~. -'~-;
THIS IS !~ QOP~"`'Q~' THE OFFICIAL CER ' ~ ~~
;=,
THE CO~.UMBU3'DEP T OF HEq.L
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