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C6RTIF(ED COPY OF R6CORU OF D6ATH. ~(~(~~~C',
Furm b~• \lichi~an peparlmeot ot Health ~4Q, •J~ • ~W
BLAPIK
?la~~.
sT.R~uc°~0V R~~~~~ TIFICATE OF DEATH
~99i3.~ K..
MKHIGAN DEPARTMENT OF HEAlTH ,
~70 ~Q = ~ 3 Virol R.c«ds S.c~ion b7-314
BIRTH No. ~ ~«a1 Fil. No. _ _ P -_1`8 _ _
~~cE oF o~GER POITRAS Z• USUAI RESIOENCE l~rineccustsurr~.nrfnrrrr~ us~scrct~an~[aMass~)
o COU a. STATE b. COUNTY
~~~a~RCU1T CALiRT~ Michig~n Kalamszoo
b. CITY (r wTw~ cNrwrc uwrs. ~att w~u ~ro cna c LENGTH OF c. TOWNSHIP, i~rc W) d. ue[s~ouc[nnawuriTSar
OR ~~•.s.r~ STAY ~iN nasrua~ CITY OR •aTrotuKOeroe~nonu~iEa
VILUIGE pl8inwe1l City Life ~LLIAGE ~lamazoo rES C~ ~o ?
d FULI NAME OF ~~r .~t n..ex~ru w warrtmw. w~ s~un ~weus ~ ioura~) STREET U? tut~l. int ~OUTWM)
NOSPITA~ OR ADDRESS
IHSTITUl10N pi Communit Hos ital N. Westncdge--
3. NAME OF o. innU b. ~rioou) c. fusT) 1. DATE froxn~l ~a~1J (TUe)
DEr~[Eo ?nwt~ Hermione S[!18 DEATH JU l~j 1 'j
S. SEX 6. COLOR OR RACE 7. M~prtiEO. NEVER MARR~EO. 8. DATE OF BIRTH ~ 9. AGE ~u~s u~oc~ t rue ~ ~F uNCCa 2~ M~s.
w~ru rn w~s rs
Femal.e ~dhite w~~wMarried ~~pF*~ Sept. 12~ 1390 I~:~J~i*~•~ ~
1po. USUAI OCCUPATION ~crr[ wn ~r ~wa l Ob. KIND OF BYSINESS OR iNOUSTNY 11. &RTH?LACE (STAiE Ot /O~OiN COYqilT) 12. CIT12E11 OF wMAT COUNTRTi
pM~ p~~•~c r+~- ..r p~anK lvt. [YEN It RETlED~
Bakery Sytsma's Kalamazoo,Michigan USA
13. FATHEN S NAME I11. MOTHER'S MAIDEN NAME 1S. NAMEOF HUSBANOOR WIFE OF DECEASED
Harm Hic~ema f Johanna Van Dam f Henry Sytsma
16. WAS OECEASED EVER IY U. S. ARMEO FORCES~ 17. Sou~i SetumTr No. I8. INFORMANT'S NAME ADDR~SS
;~[s. w. ~o~~' lr ~ts. ca[ ~u M o~r[s ~r strvK[) .
`~t"`o 4- ~+-2014 Hen S sma ~ N. Westned e
19. CAUSE OF DEATH ~DKAL ~ERTIfICAT10N u~w~? ~crrmi
1. OISEASE OR CONDITION ~TM
[rTEtOnIY ONE C~USi K~ DIRECTIY ~EADING TO DEATH~(o) Arteriosclerotic heart disease Yrs.
UhE FOt (a). (b). ~ND (C). ~
_ ANTECEDENT CAUSES T
~TNIS OOES MOT YEAN YOlYDCONpilplili 11Mr.ilYlNi DUE TO (b) with idioventricular rhvtYmi LSy.S
TNE MODE OF OYIN&, n~ TO TME ~WYE UUSE (O) STII7ING TNE
SUCM AS MEART iA1~URE. UMOEKtIMi UVSE UST. v
ASTMENIA.ETC. ~T MEANS _ OUE TO (t) and Ca~~~C failure nQlu'$
THE WSEnsE. iNluRr OR OTHER SIGNIFICANT CONDITIONS
COM?LICATION WNICM ~~pipNS CONTtlWiiNG TO TNE DEATN WT MOT
CAIiSEO DEATM. ~(~~TED (O7XE pSEASE Ot CONpT1011 UUSINi DEwill. Senile agitated depression Months -
19d. DATE OF OPERATIONI 19~. MAJOR FINDINGS OF OPERATION 20. AUTOPSYI
; . _ _ . _ . ~ -Y[s-tJ--t1o ~ -
210. ACCIDENT iucarri I21b. PLAC~OF INJURY ![.i_~MOtuour 21a (GTY. VILLAGE.ORTOWNSHIPI (COUNTY) (STATE)
SU I C I DE ~ow4 ?~w. r~tto~r. sT~T. osna nDi .crc
MOMICIDE
21d. TIME :rorrN~ :wr~ t~uer tHOUe. I21~. INJURY OCCURRED 21f. HOW DID INJURY OCCURl
OF WHILE AT NOT wMILE r~
INJURY M• wORK ? AT wORK LJ
~I, 22. 1 MEi1EBY CERTIiY TMAT 1 ATTEMDEO TME DECEASED FpOY Ju~y 13,_ __,19~_-, jp JUIy 15 s 19.. ~2.1-.
F ~J~ r
THAT 1 LAST S~W TNE ~ECEASED AUYE OII J~±~_-.1! AND TMAT DEATM OCCURRED AT_ ADArC~i__t~~aQ A~
~ FROY THE CAUSES AND ON THE OATE STATED A~OVE.
~ 230. SiGNATURE :occett oe nn~ I 23b. ~E~, gridge I z3c. DATE SIGNED
~ Welter E ~ July 1~, lg
7~
21a. BURIAL CREMATION. 21b. DATE 2lc. NAME OF CEMETERY OR REMATORY 21d. LOCAT~oN ~cm, ru~c~, in_ N awcn) (sur~
~ REMOVAL ~s?[pir:
1
MR IEC'~ ~t lIW ~i. REGISTRAR'S S GNATURE 25. FUNERAL DIRECTOR'S SIGNATURE ADDRESS
~ I t
~ Arthur N. Feyen
~'1' _~'1' I ~O I~` I I(' I I I G 1~ \T, ~ -
SS.
COCXTYOF - A~$82'1----- ! I~------------Es.~her. ~Iarner_H~tti
LK~------------
Clrrk uf said C~~un1y and _Clerk of the Circuit Court for said County, the sacne being
a C~~urt ~?t Krcord t~aving a sea), do hereby certify that the above is a true copy uf the Record ot Death of
~ .
~ . ,
~ _ - _ _ _ _ _ _ _ . _ _ _ _ _ _ _ _ _ _ _ now re~naining in my ot~ce, and of the whole thereof.
a, ~ ~ ~ ~
~,.•!"""•~•.'~n '"i . In TPS~imuny R'hereof, I ha•re hercunto set nry hand and affixed the
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~ ` . jf ~~_%;~~r,.':'*'; ~ seal of the Circuit Court the - - - - - - - - - - - - ~rd - - - - - - - - - - day of
~ _ . ' - _ r ~ ~ '
~ . , ~ • R, NQVeu~~er 1 y
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i 1,~~~~.Y}~.. .
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~ ~ '~,~,ti I ~ . - .j ~ ~ ~ .
' Esth Warner Hettinger Clerk.
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~ G-•""7~ ~ ~ _ I)eputy C ler{c.
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ti~1TY, I. In~ett •'Deputr" wfee dca~cA.
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