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~~` ~ ! 5b , OH10 DEPARTMENT OF HEALTH
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CERTIFICATE OF DEATH
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DECEASED-NAME Flsu - IMLtl/s Lut SEX + Q"/1T.E~OF E;/CT -. d, t, tw)
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RACE 1/birt,wtEH,.arirw /~Q Lrr UNDER 1 YEAR UNDER 1 own OATE.OF_ J_jffi~jRJb;~~ {OU,NT.Y'OF,D~/1TN, .-
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CITY, YIIIAGE, OR LOCATION Of DEATN ~-• INSIDE CITY IIMITi NOSFITAI OR OTHER IN 1 ,' -(I ~wo/ ix tifbtij srit'i1itM a/d wrain)
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Yours s town s~"rh't' no „
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~~ STATE OF a1RTN /I/ aN la US.A., algal dT1IEN Of WHAT COVNIRY MARRIED, NEVER MARRIED b+ VINQ E .~lJ.t+IJt, sntuei/tx at~t1
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SOCIAL SECURITY NUMSER WAS DECEASED EVER IN V. S. ARMED FOtCESt a~•>; `' ••
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USUAi RESIDENCE
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IF DEATH VSVAI OCCVMTION /Gitdada wr4ltxtlxd neu• KIND Of RUSINE~•OR 1 OIISTRY
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tE5~~2vCE 6EFORE
AC++~SStON REStpENC6-STATE COUNTY dT9, VIILAOE O! lOUT10N INSIDE dTY tIM11S STRf
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`;Canfield Road
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fATNER~HAME Fist ALidd/t Lut MOTNER~i1A1DEN NAME Fiitt _ ,.,.,..._l1)i,ld/t Leff i
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• INFORMANT-NAME MAfIING ADDRESS /St-rrr h R.F.D. we., sit, e- eiprjr, urn, ii>)
ITe. au ve IJ'-. 3402 Canfield Road Youngstown Ohio
FART 1. DEATH WAS CAUSED BY: IEMTER ONLY ONE CAUSE IER LINE fOR faJ, D), AND IdJ A-ftOXetuTE INTERVAL
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DUE TO, OR AS A CONSEQV • ,
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• "FART 11, OTHER SIGNIFICANT CONOITIONSrCoadiriest texhibxtixs fo dterb lent get rdert~ N .cart tl/tw is Nd l (I) AUTOPSY t IF YES vnt Jixdiap rortidnrd
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ACdDENT, SUICIDE, NOMIdDE DATE OF INJVRY HOUR MOW INJURY OCQIRRED /Ester setr-t e/ iajar, it jerl I er ]err ll, irt,r Id) -
OR UNDETERMINED /S-etiJ,) (IMorb, Dq, Ytw)
20e. ''-~ 200. 20a 20d_
INJURY AT WORK PLACE OF INJVlY Ar beet., Jwn, rrrtN,
' ($eti11 in e- xe) eQfitr N/S., as /S~etiJ,)
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CERTIFICATION- Alexrb Dq Ytw AEelub D.
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*-f a ~ ali;~ 1 ATTENDED THE r' !!~~ ~~ I /
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) t.IAIUNG ADDRESS-~C[Rl1f1EJ! L'~a,C~ v j.,
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€ t ~ RUttAI CREMATION DATE /!/I
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k~ :... Buria 2.b.10-28-68 :a
- i NAME Of EMRAIMER
James L
Holloway
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FUNERAL fIRM ANO ADDRESS
3 ,,. The Shriven-Allison
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Yrw AND LAST SAW HIM/MER 1 DID/O~Q~iQf DEATN OCCURRED At Ib
Al1YE ON VIEW THE RODY (MONK) 18e ~
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SIGNATV y ~ Dept. et lirl~ GATE SIGNED
OR R.f.D• NO. CITT OR VILLAGE STATE 1:11 '
CEMETERY OR CREMATORY
~rnersbur Meth
(IIC. NOJ fUNER11l D!
LION /Gt,, titf~jt, er tens.,)
Youngstown, Ohio
(IIC. NO.)
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(STREET NO.) (dTY)
292 W. Madison Ave.,-Youn<
A DATE PERMIT ISSUED SIGNATURE OF -ERSON
ATE) (21F)
n, Ohio 44504
PERMIT DIET. NO.
.FILED ANO RECORDED
ST, LUCIE COUNTY. FLA.
RECOr:I VERI=QED
18318`7
'69 SEP i 8 PM I : 55
-;OGF? ~OITRAS
CLERK CIRCUIT COURT
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