HomeMy WebLinkAbout2768 _ _ _ _ _ _ /
FORM V5.90 STATf F{lE NO.
~ - < <f ~ ~ : COPY OF A RECORD OF DEATH ? " ~ ~
: _ ~ : ~94os2
'j;r•=_
. ' ~ STATE OF /M/?1NE DEIARTMENT OF HEAITH ANO WEIFARE
- ~ ' 1M 2. UfY/1l RBpENCE wM~~ ~c~ewd w~~d. M~w+:en: rea~d«~c~ lde~~ odww~~:e~
: . -r' , '
~ . . „ o. STATf . . ~ b. COUNTY f at ~ jC
' ~~~~WN. OR IOCATION c. l@1GTH Of STAY IN lb c. CtiY. TOMM. OR IOCATfON
~ . O .
i y ti`' 4~~ ; • ,
r~; (H ww :w Iw~pa~. y~w s~.eet odd•eu1 d. STREET AD~RESS IS RESIQ~KE ON A iARM4
i,i' ?Al OR ~ . . , ~ ~ ` ~ t n~ 1. DATE Ma+th ~NO ~ ~r
pECEASED-fint Nonw 30. Middb NonN ~c. tos No ~ ,
~ ;.n 1 1 t ' 1 f ; I
g ' ; . 1 ~ 1 i.iitl ° " DE/?TH~• • • s
S. SEX 6. COLOR OR RACE 7. Mo..~.a k. rr..« w~«.~.a DATE OF 61RTli J1GE (In p~on ~~s.. ~ tis« ~t ~~d.. 2~ ti+.
~ ~ 7~ . n lost birtl~day) ~ae.. oo~r. tt... M:R
~ p . ~ vr~...a _ a.e.~.s C' : $ i i Q
~ ~ IOo. USUAI OCCU?A?IONtG:.. k~a o~ lOb. KIND OF SUSiNESS OR 11. !IR?HTtACE iS~ati a fw~qa ca+ntry) 12. CITIZEN OF WMAT
O. Q .«k dar ~w+~ ot .b.l~~a wti. ~f INDUSTRY . , r ~ COUNiRY ~
C~ 4 O 13. A 11. MOTMER'S NWQEN NAME 1S. NAME OF StOUSE t{f Morri~d)
o ~ - , . , s . _ . . r- r;.~~~ ~:~..li:.~i . ~~.`.'~"t'
' ~ M t6. WAS DECEASED EVE~ M U.S. ARMED iOtCESt 17.SOC.SECURITYNO le. INIORAAANT ~?KS s
~ O Ifes. ns, a~.) tM w+. 9~re .+or a deNS d wr.K~) A y. : R ~ t~ t. ,7 f`l . t. .S ~4 ~
n t wTERVnt ~E7wEEN
c 19. CAYfE Of DEAiII (EnM~ only on~ cou~ pN lin~ for (o). (b), and (c)•) ~r w?a ocwrn
~ ~ MR? 1. DEATM WAS tAUSED oY: . ~ f1C'~
~ ~ O IMMEDIATE CAUSE (o) -
~ tw~d:aa~s. a w~r. DUE TO tb)
~ ' K ~ wA~cA ~oti nw ~o )
. ~ a6sr~ cew~ (e) l
~ ~ ~ y;~~ ~ ~ ) ouE ro cd
\ ~ Q~ ~ART II. OTMEt 51GN~FKAMT CO~~Wt10NS con~ri6v~i~q a dw~h bw nw .ebad ~e ~M ».~.~:nal d.swu cond:+~ow q~.en :w ?o.i I(o) •
~ 3 ?ERFORMEDt~
~ ^ ~ _ r ~ c_ Y N~
n =
! h~: M~ Yto. ACGDENT SUKIDE MOMKIDE '21b. DESCRI~E HOW INlURY OCCURREG. tEm.. ~ow.• o~ ~.yw~ ~ o. r«, u er ~~.w,
~ ~ o„ O ? O
~ `C~ ~ 21 c. TIME OF ~ oer. r.w
p INJU~Y a-~
~ P~
~ s 2 INJURY OCCURREO 41~. ILA INJURII ~..o.. « eeo~.+ ~w~., Tlf. CItY, TOVVN, OR IOCATION COIiNTY STA~E
a WHitE AT NOT WM1tE rw+~. foc*ory• o~c. ?~Aa-. .+c)
o WORK O AT WORK
7 %
a ~ 420. MEWCAI EXA~AIN~: ~ F...br c..r~y xw~ a.ab «c~.r.e a ~h. nwi. '22b. MI ~ h...s,, c«uy eAe. ~ w~.na.a,+4. ~•o~_: ? )
T ond froT ~M caw~s swNd ahov~. und ~ho~ 1 Mld an ("mvntqaaioe) (uWeP+r) ~o :~~j ~d to~~ wx M.w or~w on i~ 4oM «~wred
• en d~e rnwoi~s ef Mr d~cto~d m rpwrad Ia... o~ -~r . i. w.. on th~ doN end frwn ~Ae cors~s srored obove.
~ Z3a. :IONA1URi tww» w ad.) 43b. ESS . ~~c. DATE SICNED
O , ~ 4: j•1')- ~1-1 ~ ~I
2~0. wnw~. ce~w zsb. D~?TE zrc. NAME Of GEAAETERY OR CREMATORY ~~d. ~otwT~ it~h, wwn, or coumr) (s~o~.)
~ . • eE'r°v~u ts°~`d'~ • • ~ ,
~n y : t . I ~ l 7~ -'•n 1 ~i ~i .~f4 ~vi'Ti ~~i t+~l..: ~ J Y i~~.? ~r :S }q, ..it 1
: ~
4 4S. FIJNERl1l DIRKTOR ADDRESS r~ ~ 26. OATE/~E£D~ ~x,~ocw? ~c. 4~' R~IS~ RAR S F' .TU~E y. 3-; f
• . ~ ~:~~s :'~:h~-: r~ -_a'.. ~ .tc , t%1 ~LL '
~
~
•~.I
~ ~ 'N"f'R
• ~ ~C~1
~ O
RE(70RDFR' S MEI"D 7° Z
~~g N ~~v
Legibility of frriting,
or printing unsatisfactory c o ~
i
n t
h i s d
o c u m e n t when recorded. o~ N~~~
cv' ~~w
_ ~
~ N p,o
.
aoox ~ac~~~~J
{ _ _
~ - - - -
. _ _ _ _ ~
_ _ _ _ ~ .y
v . .T
~.a. _ . . ,