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HomeMy WebLinkAbout1553 . OH10 DEPARTMENT OF HEALTH 1SS~lEj Re~. Di~t. No. ~ OIVISION OF VITAL STA ~TIGS Statt Fik No ~ Pnr.:ary R~~,. D~lr. CERTlFICATE OF DEATH Re~otni ~ No i. PLACE OF OEATH USUAL RESIDENGE Iri/herc deccax i~.cd. 1 msutution: Rcs~- o. GOUNTr d~ncc before ~dmii '..n) , :~a~nilton STAiE Ohio r. coo?+r ~amilton ~ b. C~tY, V11tAGf, OR IOCAIION s. IENGTH O~ SiAY IN 1• _it. CIiY, VIItAGE, Ot iQCAT10N s c: t ~~c~ i nru: Ci ( Andcrson Township J. NAMI u? ~JJ w.,~ iw A.v~urJ ri i~~ut~lr.r. jiri ~f~tlf rJ1it,~) d. SiREEi AOOIIESS t10.NU1 OR ~ ~~s?~,~~~oN ~oa:i Sa:narit:~n Hospital 8033 neecr.r:ont Ave. IS ?I~CE Of DEATM INStDE CIiY tIM1iST ~S tE510ENCE IHSIDE dTY IIMItST IS RES~DENCE ON A fAUA1 res :j• reo D t res O~+o C~ I rES D no Q y 7. NAME OF F;nt Mfddle Ls~t aAiE MontA Dar Yur DECEASED ~TYtE OR ?RINT) n OEATM Chesti~a Rob P„rter Senteraber 11 t 1~ 4!. S. SEx COIOR OR RACE /~tR1ED Q NEVER MA4RIED Lj DATE Of ~ilTM AGE !1~ )t~r~~ y~~ ~ Y~ y~ j~ Mr1. f !yf Iirtilq/ M~*rb D~p ` fl~eq Mi~. I w~oowEO ~ crvo~o 0,11-28-188 ~I ~ 1 ~ 10e. USUwi OCNMTION IGn~ 4id rr~k les~ IOL. KIND Af WSINESS OR INDUfTRY 11. HRiMtIACE (Sr~tt or f~rtr~+ 12. GTI2EN pi drriwy ~.os~ ef roriG+y Gh, hrN :l i~w~d) t~rwtry) ~ WHAT GOUNTtYT ~?n _hold Self Ohio ( U.S.A. i~. FATNER'S NAME 11. MOTMEt'S MA~CFN NAME vi~ :dll ~~n Aurena Griffi~h 1S. WwS DECEASED EVEt IN U, S. ARMEO fORCESI ~~s. souw~ secu~~Tr rro. i~. ItdFORMANT'S SIGNATURE ~ddres, (}'~f. ws. er cetno~r~Jl (If jn, lirt rn ~r lau tnsirr) _ 1? r ' ~ , ia. CA SE OF DEATH [E.u? •J~ cs.,r ~n l;.~ ~er (i , (r).) n INTERVAI tETWEEN ~ I MRT 1. DEATN WAS UUSEC tY. • ON~ET AND OEAiN Iru?EDIATE CAUSf fe) ~ i Co~Jitiewr, if ut pVE TO (61 ~MM~ _ ` ' ~ ; ~c•birb sart rue to i a~nrt ttru (a/, r~ ~ rJilraa 16t rRJrr- OUE i0 fd l~isa uarr~ lar. Z n~* u. orwu sicwvwur twMrws to~num~~ » Cnu •~r s~r c T ~ p~~ o~ Mn u~u* d~l If. WAS AUTO?SY ~ Q (E ~O V 1 1 . ~H. IERFOlLAECt - ' ~ E v ~:'-COt l V~ F:iFiEb YES ? NO ~ = 20e. ACCIOENT SUICIOE HQMIdDE TOL. OESCRitE l10W IN1U~1/ OtQ1RtE0. /Entn ~us~ ~~(~.f ,~r /irf /1 • ire~ IA.I W ~ a o .i. :~1 . ~ ~ 4 < 20c. TIME OF Her• M~~~b, DtJ. Ytt~ ~ 'a ~?+~uer . ~ o s~. '~(~f- . f IOd. INlURY OGCURRE~ I 20~. /IACE Of IWUR1/ f~- 6•. !O 1/ IjI~! AORl~ ~ ~OI. ~ITT, VIttAGE, OR l TIOlt COYNTY, STATE WN~IE AT NOT WMRE f~w. /irt•rY. ~nnf. ~firr i/d~.. ~lr.1:t~ ~~t: r'Q~~~QS ' WORK ~ AT WOR1C ~ ~ ~ 21 1 ulrwlyd ~bt durutl Jrew ' ro___ % ~u e q~~Jiri o+r ~ ~.rr6 ar«+rud it ~ . G'.'w ow ~bt l~rr ltirrl i~ I: ~1 re rbr iqt w~ Isoivleljr. Jro~ tbe rui~i il~f~l. ~ - -f- • 2z . SIGNATUR (Uipn ~r fi! J 22b. ADDRESS 22 OATE SIGN D ~ • ~ t.u.~..~ -~~i l ( Z..'~ 5Z~ ~c.c~'tc~n.t t~.'L. • ! / ; •,,,L.,~„ . ~ 7~0. 6UR1~t, CREMI?• ` Z~b. DATf ?7c. NAME OF CEµETERY OR CRExATORr ~ 21d, tOCAiION (Gif/, wwn, oc counry) (5tste) ?~ON. !$P,,:(7~ ~ :~uri ~ ~-1 ~64 T~it.:~~ori ,Pri .+.?rv ~'oba~sc~, Oni o ' ~ 1~. fiAME OF EMlwIMER ILIC. No.) ~ 25. fUHERAI IRECTOt'S SIGNA U!E (Llc. MO.1 l~~r 8_:. .~27?~A ~ 1'~i.Lt.Lr/G~" ~ .'~79 : f~ z6. FUNE[~t flnM ANO ADO f5S (SitEET NO.) (GTY) (StATE) s ~ T. ~'.'rr'r~ite tc :~o s 20 ~ Beech:nont Ave. Cinc~nnat 0 Oni ? ~ I7. DATE RECD ~T ~ [EG~STlAR'S SI N TUtE ]9. SY~-IEGISTRAR'S SiGMATURE ~ : ~ ^IOUI REG. w(1^S: ~ .i ~ !t ~ . ;'S ~ • I : y;: a:- ~ ~ f , I~'fl~i~orM f1 '~'~i:' . ~ . . . . ~ I h~'reby'~c~~~~t ~fiis to be a trus and oorrect photographic copy ' - a~, ~.ti~=centi~ic.~t~s •son file with the Cincinnati Board of Health. - y~ ~ ~ ' - ~+7'~ c" _ • ~ . ` _ q ~ . - -y i ~.7. ° - h ~ . . ~ " R t - . ~ ~r ~ ~s y',' • . . ~ F• s _ t~L l~1- , ~ ~ j'~~~ ~ ~ N ~7 ~ c5~ ~ • ~7Q~ •~9 ' strar . . ~ ~ e~~ ~ ` ~ .;.s ~ ~Q~~~~ P~f,~1~~1 ` ~ . . . . . . ~ U~ ~ ~ . ~ _ _ ~ t ~~,:~s~....LLw ..v _ . .~~w~.~~~_~