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Home My WebLink About2124 STAT! Illt rM ~q. REGISTRATION iTAT[ OR ILLINOI• ~K~ 1~3f 5~ DISTRICT NO, p aEC,~srEaEO MEDICAL CERTIFICATE OF DEATH NUMBER ECf/15E0-lVAME ~ r?~ ~T SEX OATE OF OEATH wa.n~ wr. vw? ~.rs. Juanita - Josephine Carter Erickson ~err~ale 3. Decer..br.r 1~, i9E` K'p, RACE wNTC ?tu~o~ wrauuw ~+piW. AGE- UNDER 1 • UNDER 1 OAY OATE Of BIRTH rwn~ w~ +~uw PLACE Of ~EATM ~~T`~ ,~+s 'n'hite ~ iSe.M106' ~ a?K ; ~ ~ s. June 29, 1R95 ~a :~ock Islan~ aTV, Tow~+. Tw?. aa ~wo asrmcr ~ww~ai ;~cm ; wsnr~t w or~a o.snnmo~+~urt a~ ~ w arnw,cro sn«n ~uo nu+uai ~e. l:oline ~~G Yes ;~e. '~r,eric3rn3 rursin Home BIRTMPIACE ar~~ c~nw CITIZEN OF WIIAT COVN7RY MARRIEO NEVER MAitRIED, NMAE OF Sl1RVIVING SPOUSE N wn[. cM w?qw M~ cou?+rnn WIDO E6, D~ CEDa~c~rn s. Keo~s~uqua, Iaw3 9, U.S.A. ,o. ~$rrl~e°~ Carl 4. Erickscn SOCIAL SEGURIT1l NU ER USU UPATION . ~uno os ~us~NESi at tnaiSTnr ; U.S. WAR VETERAN. WAft OR DATES OF SERVICE Forela ~ Tailors - Gibberrr.a~'"01 : ~z. 331-07-~835 dY ~i~ s ~ ~x. ~ise. RESIDENCE srwrt : cou~nr ~ un. ~w~a rwr. aa ~wo asn~cr w ~ nuwctrtr . stiaM ~wo wr~n 14a Illinoia Rock Island Z'oline :,`~es ; Box 29G, R. rnest rrootc usT TNER raisr waat usr ~ Charles Carter ~ Josephine siifi;lan IN ~ , RELATIONSHIP ~ NWUNG ESS an~ ~wo Na aR ~ r_ 0. rnr ai Tow++. s.~,i. zr~ ~ l ~-'~,7 ; Z;ortuary Reoo~s 1216 Fif'th Ave. N.oline I~:. 5I265 VART 1. OEATH CAUSE~ BY: ta+rca ow~tv O!~i swusE+~ ~~M. M. wo fdf ~~[w1PO aiT woM~otwn~ _ FiLEO AND RECORDED' to~ a,E,oo.~~ca+s~a~+e+ao' j?F:Cnr=f ' . co.~o~Tw~. K,u.~, t F 1' ~iaw~tvE~ ~yn~[ tq6 - . STAT~NG TK {M~OER- OUt TO OR At A 00~6Ep11@KE 01: 1111NG CAUSE IAfT. '7 • P/1RT 11. OTHER SIGNIFICANT CONOiT10NS: aw~wriors ooieniwn~s ro ourn wrr wor w~~eo w ws ww w Y ra. .n. .~.o..ea eo.- I ` ~Jl~C7 NO ~ a a TM•• anu...+s vw ~ 190. .19b. DATE OF OPERATION. IF /W ~INAJOR FINDINGS OF OPER/1TION : PQIT~~.S ~ CLERK CIRCUIT COU ` zoo. 1 CEBTIFY THAT TO THE BFST OF MY K1~WWLEOGE THIS Df/1TH OCCURREO AT . M., ~F AN INlURY WAS IM/OIVE~ N ON TME DAT~, AT THE PLJICE AND fROM THE CAUSE(S) STATED ~i •3O P• THIS DEATH, THE CORONER M~T 21. BE NOTIf1ED. OKEASED ROME ~TM . wr . rt~ut~ ~o~+rn . wr . rua ~ wNO ua s~w MrV rwtN ~ a?r . rw Z~o. ~-~Z ~ G7 Z~b~'~ ~ • Gg ~ ~ w~m o.t ~~Z ' ~ `G ~ 51GNATURE . DATE SIGN~ wr rw) ~ IlUN015 UCEr:SE NUM6ER ~2Q~ f/ ~~zb. ~2 ~e ~ uo G~ 8+/6 MAIUNG ADDRESS-CERTIF/ER smca N+o Mwre~ aR a r. a arr oa mwn srwrc n• / 7O - ~ !/E. i~~%rvG GG. BURIAL, CREMATION. ~CEMETfAY CR TORY--N , atr a~ toww sTwr[ , E wo~+M o+?~• REMOVAL tsrtcun z.a. Durial ~s~iverside Ce~etery ~zk. Moline, Illinois ; 2,a. Dec. 19, 1966 FUNERAL NOME PIAME f1~tEr 11W MNDOI Ol R f. R C1?Y 0~ TOIM~ RATE tA 2s~. Esterdahl Mortuary, 1216 Fi~th Averrue. Moline, ~ Illinois 61265 .wg~o~~s ~ . 9/ ~ , . ~ou~ a Wsnwr s+ ~ aEC~asr a sne~a~••...M• . ~ J~ ~ 2 2 VS 400-(t96!) Kunas ov~ur~wcxr a~ie ~ww~rn - w~euu os sTwnma ~ e~?sco oN nw u. s. sT~++ww eunnewTO ' , • - . I HER~BS/_ ~ TNAT ~'he ~onego.ing .ib a fii~.ue and co~cn.ee.t eopy o~ ~he dea~h ~ceeond ~on ' zhe d :;o,~.~b. ove, and xha;t ~ ne.eond wa,a eaxa,b.Gi,ahed and ~.i,eed .i-?~ r?u! v~ 6~i-~e .i,n ae,co,," 1?~v,i.a.i,ona o~ Zhe IX,~. a~atu,teb ~e~a~in9 xo #he neg.i.e#~ea~i.on o~ b.ili#llb, ;a6;~~,~~a1~td~:"~!~" , ~f ~ ~(~f~D ~ • ~.b M• vaTE~ ^ : - ' D . ~ ' Reg,~,afiia,an. r. f;~ -vepu.ty T < ~ _ _~.4 ° i ~ I.G[,i,ltok6 - ~~I LE Loca,t Reg.c.b#~iM ` a ,.~f AbX,~,rie , . ~ L~" ~ n.d o b fi~.i.a deaxh ,i,a ent~Cy ~i.Ced wifih xhe I.GL. U¢pt. o~ Pub.Gi.e The onig~in~t- ~eao 1~~ ~ 5,~~• o ~ 184 ~~12~. ~ BOOK - ~ _ . _ _ , - ~ ~ . ~T~.~