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HomeMy WebLinkAbout0663 . 19,26J1 g~TI~,~p~ CITY BEAI.TB DBPAI~1'YLNT , BUNEAU OF ?ITAL RECORDS . ._OBDFfl.Iffi.- - - - ~ ~ 3 I : ' - . , _ ' - ~ . - . ' BAL7IMORE CITY HEALTH DEPARTMENT 1i ~ r ~ Re istered ~o.' ~ ` B~R ~f ~o f CERTIFICATE OF DEATH E ~ - _ _ 1. NAME OF DECEAScD . / 2. DATc /1,+` r f ~ (1yPe or Print) . f _ s~~~ - • i~ w/ / _ ` L~ i ~ I D ATN ~ = • ~ ~ ~ V L J, - ~ ~ ' . ~ .1.PLACE OF DEATH: ~ T ~ 4. US~JAL R°_SIU[ICCE 1\\F.•r<JCcrss~11i..•d Ii ir._:iiu.t~~•n:r >:~i•.~•.• _ ~ A. B$~tlll:O!'C CI~Y, ~Earylnnd " - ~ A. STATc r. ~ ~ • e. COUNTY ~ l+tF.ur •s~~r+it_+eue.; ~ s. FULL NAb1E OF (It uc•t ia h~~yit.+i u[ IW[ll:l(t~•A, gi~e a:rrrt ~d•lro++or r~ . HOSPITAL OR • ~ Iric~tionl C GiY 01t TO\YN ~Ifoutai~lrr.,z„ut~t.•lin.its,n~rit.-l:l~tt_11.~ad;:%.~ A Ii4STITUTION ~ t~ , f~ ~ ~ i U.~:e.shi{• ~ ~ 'r-- • _ . . ~ t l!/ , • . . i _ / . , r1 w~ ~l. - yit. o. S7 k~ET AUDREi3Sl~~1{ rural. gi~•r Iu.a.i..t~1 r 1 r [ b ~ I ~ ~03. . . h f" ; ~ . ~ i f ~ . y ~ l•. ~ ~ _ ~ a; c. I.en~th of st;t} jn Iialt:mor~--=- - - - ___nar~ ~ l _ 7; , ~ / • 1_--`=~--- - - ~ y 5. SEX 6. COLOFt Q~t HACE S~~1~~E. ~~aRR~EO. 8. oAi c OF F31RTi-1 d. AGE U~ Y~•~r; C i:':.t l i'3 C U-c_ 2S Y:_a ~ a , ~ • I WIDOY/EO. DIYOftCED (~;rcit!) ~ ~ ~ , ~ -•ti t Lirti~d>> ? ~~1unlEsi Days I2[wr~: .lin- " j. ' f i ~ L:}~' ' ' . . . 2 ~ w IOw. USUAL QCCU'rAT10:t U;i.~~l~odo! IOe. KIND GF 9}'SINE53 Ot 1 i. B~KTtiPIAC~ t5:at.• vr f.•r.•~~u cauntryl a 12_,CITIZEN CF p ` •w]dau~du:iqmwtdwu:lEesiGfe.e•ru:freeired)+ . " ~ 'J ~ _ It:DUaTRY • . • ~ - ~ a I WHAT COUNTRY O V _ . • i. ~ I - - . - ~ ,r.- " _2• ...1! y~y~+ 13. FATMER S ~:~t4E • ld_ A.OTNEK'S l+1AID'cN (~~t-IE w. N q ~ . ; ~ . ' , ' ' ' : w s: - ~ ~ f • - . .t.~ ~ ~ _ ' ` azi wp~ 15. ~YAS DECfASED EYFP It~ U, 5 AR4E0 FO!tCES? 16. SOCIAL 17_ IN~JR6!At~T ^ ~ ADDRESS Q M O ~Yc~.[fOOfYQLOYYC)I (~t7eaeiov,uord~te~otacnw<) I SECURITY t30. ' _ . ~ ' _ _ - t~ , j ~a Cp7 ~ - ~ ~ 1.)~!_~ ~ _ ~ _ . . j _ • , . . M r, - ~ ~ O ~ ( I8- . I .I CAUSE OF Q~ATH • ~ ~---`IH7ERYAL BETN'cE1t~ . a u ' OHScT AND DEAIe~; ' 0 a~ v DISEASE OR CONDITION DIRECTLY ' ~y "',q ~ LEADIftG TO DEATFI ~ ~s~' (This dxs r.ot mcai~ the male of dyine. e.Q.. ~w~ -..._.....!-.'!'-.'"`l..`.-.-.. _..~'..:.r.:s~l. ~.~~~(:Q~.~E~~, 4" - _ ; ~ ~ heatt failure, as~F _ nia, ete. It mesns the disras~~, . L C I E C 0 1 Y, r• LA. ' ~ 3 injurr or ea:nDlication schich enascd d?ai!~.) DuE To ~ ~'.r, L'Q ;~lERIF E E R: ANTECEOENT CAUSES r, • S - W ~ P; „ r ~ .?4• t-. . . . . ._o . V~ Z ~s1 . . W~;, Q DISEASES OR GONDITIONS. ~F wyv, clv~Nc py' ~ RISE TO THE A90VE CAUSE 1A1 SUTING 7t1E OLE TO . 'l0 APR 24 P ~ ZO UNOERLYIhG CONUITION tas7. 'j,~ ~ ~ V ~c? . . _ . . . . - N _ . ~ Q V' ~ ~ ~~"^U ~ Oiri[R S~GNtFICA~:T eouo~.tee~, COtvTRIBUTIDiG . _ VF R ~ ~ w;. ~ TO THE DEATH otT HOT R=lAlEO TO 7HE . '~Q S'O{7Ri~S; ~ ~a u o~~~,_~ ~:~a;,~:: ~Y. - . - ~ ~ EaK CtRCtitT GDURT,~ ~ !9A_ UATE OF O?~RATS0II IJB. COi~D1T10?7 FOR \Y:iICN OF~EF<:.T1~):; ~ IF U:•~RA710tt Y/:.5`kEtAiED TO 2J. AUTO?'.iYi 4YAS f~F2tOR!~SED CAU.iE OF U~.iTH. Ci~TEtt IN ~ ~ F( I Pl.kT I oR PAHT 11 re31_..) No F' ~ ~ E - - - c! U 21w. ACCiDE:2T ~YAS U~IUEf?LYIE:G[1{ 21~. PLAC~ Or I~i!l:r.Y (~.e.incr~ 21~. ~~tt'cFte UID lft ia F>slt~c~.re Cit_. Ricr ex^~:t lu n!ennl OR CONTRI6UTItivi~ CAUS~ O~ I~LootAoroe.ta~m,lwwq,e:n;:,e^~uidSS-.<tc`) iNJVRY C:GURt FI O , W DEATH :KOTIFY ?!~fi1CAL EXA41A~'H) ~ C' _ _ ?a ~ ~ 210. T17.?E (~lu:ith) (Day~ (1~rar1 ll:aarl 21~. Ii~JUitY OC: U~2F:GD I't t~. h;Ut't CIU INJI~i<Y UCCUR? OF INJURY ~ I ~i!!ILE Ri? NO: bH:LE~ ( ~ ~ Sn. tlORt 11T wO:R _ .7 a --j_- - C . . ~ r . ~ - 9: I ln.st satr t~., 3 C, ~ sa. l hcrcLJ ccrtijy(..at I a.trnc.cd the d:ecascci j>•oe,i---.'-•- ----,.1---, lo--- 19._, ikat ~ ~ (tCCfQ2Ct~ Olfi' G' . 1~-=~--• Q!?tZ ~JI~J~ fIPC*~i? Ofi~lTYC~7lrt_ .~1~t.. t>'AUt ~i!? 1'4~iISPS Ar_:: V3L t~t~' OtrLii .i~~:'i: (.,T C_).;`' ` H ~ ~ ~p ~I 23A. S!G ~U 1 ~ . . ~ . . 23d. AC)L~tiE55. . . ' ' _ 23C. DRT£ SiGGJti:~ ~ ~ ~ t~ . , ~ - : - . C1 - K~ n.~. - ~ ~ ~ G I 24A. ``E!•~ AL. C S ~6. G~ 24C. NA.`.!F OF l:E:.ic.l~:_-ttY oia C: ~i•7.~TOHY »n. LOC.a'tO:J !Cii., Lwrn.o: r.,Lr.[y) ts:.•~ ~ ~ ~ T10:?. ~[c{iOL'n! t~ .cii a .If - - - I - - ~ ' ~ ~ P~( . 1: I , 1 ~ W H I - L ~ ~ UATlRR I •B RE Slv~lATU~t~ , a5 FUtiERA[_ L_~E~CTOl2 , ADDRE~S P~ v LOCAL 1 4RR - ~ - . - L-- A_ ~ __,C1-~ ~ ~5 1 ~ ~ ~ - ~ ~ ~t o~. . . . . . - ~ 'IHIS IS 'lb CFA?IFY 'IgAT 'iHE ABOVE I3 A 1~[lE COPY OF A CERTIFICATE ON FILE ~ IN 1HB 8~11.?INOHE CI1Y HFJ1L1~i DEPAH111II~IT. BALTIMOEiB, MANYL.AN~. . , ~ 1kAIiNING: DO NOT ACCEPT THIS 'I~iANSCHIPT UNLESS THE OFFICIAL DEPAIi'iIYIENTAL SEAL IS AFFIXED HEREON. PLEASE NOTE SEAL IS IN BLUE. , - - ~ . 600K'~04 PAGE.;.6~ M.D. ~ ~~~~r,~R, ~RF1?U OF VITAL AEOOEIDB OONMI33IONER OF HEAI.TH AND AEGISTAAR. h - _ -