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HomeMy WebLinkAbout0080 ~ , . : _ . . _ 1QCROFIIY Y~IO Le~ibility oi .~itins, typins or ~ Pxintin~ ona~?tistaator~r in thi• docv~eat for ~icrotiL~ins. ~ araaasu~.• vr VVLYWas~A ~IaKA~~~~va~~~• s_ j~- 65 ~ 1448 ~%~~5 F~~ 2?. I'~;1 I?_ cn+r~c~?rE oF n~rx ~1 / . ~ i. r~,?cs or nuia ' 1 N1u1E OF N06PR/U. OR 1NSt1TUTtON Ul ~a A A..lie.l. w...en~t .J~n..) , Washingtoa. D. C. `~1,(ti L~... ~"r~ ~ ~i, . ~ c ~li ~ ~ ~ -s t 2. OS~JIi AZlmL11Ct IIAen ~ae~~ tis~1. 1 aWitrtiN: R~w/rw ~/wiri~w ~ a, h NTY a Cl77. 1'01NN. OR IACA7iOK i~~~'.c~•?~ C/~J'Trr O/i'lciE' a xl~~ d STRFET ADDRFSS w 1S AESIDENCE L7TY LAl17St 1. lS ON A PAl1)Rt ~:_~r~ 1l~-~. (c~-i~.....1,?~•...z. ~ti~•.__ 3 YES.~ tio p 1~ESp ~ No ` . ~~em of in.. _ ' xaxz or r.,,r , ~uw~i. r,.a ~ u~~ x..r~- nnr-- _ r.. - - - :~should M atCEASEp ~ ! ' ~ ° J j ~ " _ . supplied. (t~~s w l~wN ~ f{ t~-' ' ~ ~ 1~1 f_- R ~ D~?!H .2 _ ~ ~ , S. SEX 6. OOLOR OH RACE 1, r,aw 0 xas f~' ~ DATB OP ~ s oxw t Tr.a w axMa a~a ~ `l.~ ree~s 0 M~cn ~ J' C ` tI Jf«uA~ Dqn Aw~ Ma. ~ 100. IISVJU. OOCUPA710N ,(Cisr li~I w?~ 1aw~ l00. CIYD OF DllSINF:SS 11. DIMHPLACE 12. ~.17fZtIi OF 1NHAT OOVl1T11Y1 . ~nmes a per• 1rriw~ wo~f ~J w?4iy t~h. s....I ..r:st1 IHDUSntT (aar• Mw+~ c•~n) .,yai :ecara ~ . ~ - . s c_ <<~ r l ~ . i •;prtly ex!- 190. FA'RlER'S NA?tE 13b. !10'lHEtt'S i[AIDEN NA1lE ~ t~. NAlIE O~ SUttV1VING SAOIlSE ~d~'~tC=.'`S ~.t.t~ 4~+ ~ E G! .tJ ~iC .~D t..ta , \ 11. . ` ~ . ~ 15. WAS DDCEIISED EYEA IN U. S. ARi[ED Ft+RCEST 16. SOCIAL St7CURITY~ l7 ~U/AIlt,~) RsLA!lON3?!/r ?'O DeCSIdSD ' (Ya. .~or rwkworw) ~ra. Ms~ wr. ~hta et ~.~n~ce) t Z,° ~ [i ~/v/~ ii.JO ttJ • ~c3/IF~C 3 ~7'~J ~ /0/~'Mrc+ : ~ ~ ~ arite pfain- 18. CADSS O! DEA78 lBwta Nly ~we e~we ~er fi~ /e~ (b): u~ (~).1 i% w~v ~1 : permaneA! PARt L DEATH WAS CAVSID D7: 11. ~ ~ ~ , r : . ~ . ~ ~ : ~ ~ ~ 1 IDt~tFAlAtE CAtJSE tnl ~ . . _ _ ~ - • i S ~•^r ( ,C,(~ . ~ CoditiMS. il. ~wr. DIIE 1'O lW _1~ ~ ~~1.1 ' ~ ~rhicA Ner s~ss to ~ ^ ' ~boe+ cswe + stetuy IAs w1e- ?'L ?O SVB- 1~. nwe 1ase. DUE !+O (d 1 CERTIFI- - ~ PART ll. OTliSR SIQN/PICA11?! CaHDl?lONB wnuwnxa w w~ara nrr ~r ~o+~p w tws myi~ut. wsus a~swr a~ u~ wt it~) ?F DEATH ~ 19. w~~A ~ Y DEPART- ~ ~ Np D :F PUBLIC ~ wITHIN ~c 20s. 1tOCIDEtiT' sU1CtDE xOM1C[DE ZOb. Dfi~CRisE HOw INJURY OOCURRED. cs~tes ~trn.l ~irlr r Ftire « e itcs 1~.) ° s AFTER " p O O :S A VIO- ~ OF THE ~ 1N)uRY" ..~w. °"t • r. ~ . 0~ THE ~ ~ 20d. INJURY OOCUARm 20~. PLACE OF INMIY G. I.. i~ rBNt ~owr, CJlY. TOWN, dl LOCA710t1 OOUl1lT STATE OF CO- h~. l~o?~?. atnet, olin itll.. ~ee.) aeus ~ x~r wras ~ aroac ~t raa~ 21. I atNed~d ~ a~c~w~d tro~ Y.. ' 4d Ir! ~sw ~ sr~s M! 1 L~ ' D~a~ eeeo*r~d aY~.'•2•T • s a~ O~ MM ~t~W ~ns iY N M iM1 ~t ]~rl~~ tia~ M w~N std~. ` , of ihese L• 22b. ADDRFSS ~ DA •a ~ wnishabl~ ~ stc~f LC.,~ . ~KC` w. A / ~7/i~ .~Y.~C~~: .~l./ s2 •.~/-(oJ ~ o: impris- 290. BURIAL OATE 23a NAME OF C EI~RY OR CR . . ATtON (Cit1, hrw. or cw+d~) (&~ts) :r both. cR~wnoN , ~ " - - 8t]dUVAL ~ '~'~'4'~l .C5C'.YC4i/rF'``ih~ ~`rCF . . P 2~. FUNE7tA6 H. Y~.~V7l3E.t.°lra ~•tJF'.l~ .A' A! ta=; " ATUAE R~ UN ACFR'S ~ r__. : ~ : REXiISiRATION ~ y~ , `3 ~ ADDRESS / ~ Tl~C.~T. .U - t-CJ. r;.:.;~, NUMBER ; . s ~ ~ ~s`~a'`- ,c...~ 3 - , _ ~ RECOaoEo RQ/ARKS: _ r , - +i _ . ' ~.~~f ~ E e o - ~ ~ ~ . ~~=%~-.C=~R~} c_RIFlE e? i` . . r~dr.~f=-. ~ - . , ~ . ~ ~ ~ • ~ - .-~z;." ~ _ v --_rT~___;, ! . .,y~_. _ _ _ - ' ~.s.,,~aly?. • _ . ~-i i + • ` - , r7' ; r . . } i!~ ~ ~t. ' Date i ysued ?~over~ber 25~ 1969 ! ti ~ ' - { ' - ~ ~~~f~_-~/' T;] ~ - _ . ' f..~ i•. V V • ' OI i [~NS TH I S I S i ~ CE(~T I FY that the above i s~ a= tru~e and c~r?tp~etCifS~~~b~8'+A~~a~ ` ' of ~th~ or i g i na 1.cert i f i cate f i l ed N ith the V ita 1 Records D i v i s ~ or~ of artment of Public Health. ~ ~ the D~strict of Columbia Dep j ~ ~ NOT VALID WITHOl1T RAISEO SEAL . ~ i~ ~ f ~ ~ s. . . ~ ,j~ 6~~~ P~CE John H, randa I 1, Ch i ef _ _ _ i~ . ~ Vital Records D~v~s~on _ _ - . - „ - _ - - - - _ . . _ _ - _ - - . . _ . - - _ - - - - - - . . } _ _ _ F ; r - ; ~ ~ ~ . _ ~r - - - a. -a: .r"~`". w . . _ _ ~ ~>_=.~t_ a .n~_