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HomeMy WebLinkAbout0476 ~1 I he.r~by c~rtify that !h• for~goinQ c~rtirioat• i~ a ~Q,~j43 tru• photocopy of ±he record on f31e 1n thia otf~~~_~ a ~ : hi• day a f ' 19 •~~1~'~' ~ f;: ~ ~ ~.A~ ~ ~ ~ ~~~~~.~.,,%s ~~Ii; S ~ ~ ' ~ . • •'r.l ~ . LORAIN ~OUNTY~ OHI4 REGIST?:4 ` \ - ~~c~i ~ , • ;;G~^y ~ OHIO D;~~l~t~NT~ ~"--~:~~ALTH • K tH.~ _ s i ,i; - ; - DIVI$1 ,al~{:~ ~`V!T ~ ~~.STIGS ~ ' "~~0~ 1'nn„t) Ha1C- U~.t. X~. ~~31-~_ - CER~ • h s~' ji_j f:.lc.•tw .\o ~ RAT H OECEASED--NAME ~+•,r .HiJdlr i~,/j~ ; ~ EX ' ~ATF OF DEATH ! Ne~r!•, D.ai, Y~rrl :r ~+p~ 11\~ . / 1. r.~:'' ~ V~ ~ 2. a~eT.;"1P ~i/'~~l RACE w~r~,r~, Rf~~V~'J~af~I~JN AGE-- l..~~ uNOte 1 rE~~ u?+~Et t r' Q~iE O~ e~ttn • u•.+,~~. ~~_.~COUNYY OF DEATH inl~~~. rfa~ r~~..j!1~ ~u~bd~ r ~ari) \lo.. 1 rl~ lfnMri .~I/M. 1~..r1 K ~ ~Ihi „e _ 1~ se s~. s __~13 ~L`-~ ___~,rr~~~ n _ , arr, YILIAGf, Ot tOCAI .!N Of DLATH INSIOE CIT'I 1tM11S NOSt11Al OR O1HER ~NSTIT~iII)N- N~N( ~ 7 e:*:n rub~~, ~ut ll~t[~ dIMI ~r~~f/1 Ilp~u/ ~n or ~ul , Ar ~es ,d 140 ~•.u~ ~ T~u-- - - STATE O? •IRTX +f' ary! iti ~•~..1.. +~..rt CIT~2Eti Oi WHAT COUH~~~ MAl~~fD, NEVER ~eA!l~ED. SUR~?'6JSf ~ h u i1t. jnt wr~+d~r w~~J ~ +~r~~r~1 ~iDOwEO. D~vOttE~ ~S~+rrJl~i Vir~ini o`U.S.A. _~~o rtid~we~._ L~_ . - _ - • SOCIAI SECUttiY Nu~rtER ~M~1S DECEA~ED EvE! IN U S. ARMEO fORCES' ~ ~l~tb K4. ~r rwtwow~+~? ilJ is~. R~~~ ~~+r r•r dal~, -.1 ir•~:.rl USVAI ~lSIpENCt I2~. 17~. ~ - wMHE DECfASED UgyAl OCCYMLON 'l.n~ iid ol ~+r1 de~e Jr.i~a ~o~f o/ K~ND OF^SUS~NESS Ot th~USilr UvEC. if DlAiN A.~r1i~s li)t. r~~r i? r~tn~J~ o~a..~o~N ~?ou: ewife - - - ~~.s,~*u,a++ c~vE ~se. ,ae tEStOEMC! ~fOf! . lES1pEN~E-STA1E C~UNTY i11~, VI~tAGE Of lOCwiIOH INS~DE CItY l1MIT5 ~~1REE7 ANO NUM{E! ~ ~oM~s~~a+. ~Lake ~.~~~il i f~:or rn~ ~ sae l~J ~bu21 ~?venue ,.a. (~hi o Lor? i r. -1vor. fA1NER -N~M/ In~t .~Ldd/t IJ~I MOIMf• MUp[N NnM! /...i 1tajJ:? ~.n1 i ~ i~ayfield • :`,~11 ie Lee _ _ Y ,s . Z INFORMANT--NAME MAtIING A(~ptE~S ~~r...: A.?.1?. .,r ~~u..~c~. •~.u~. :~P~ ~ ~~a ~ ~_:s, T~:~ ~~b.? ~t0 I~ }.~l ~ a~~f~:~~~E: ~r~- ~~i z rMT DEATH WAS CAUSED sr: .ENifR ONLI' ONf CAUSE Iff i~NE f0! ta:, rb~. ?N~ r~; ~???ROZ~MAiE INt ~V l ~ ^_____~_sE~WEEH OnSEt wN0 DEAtM ~ 1C. / " ~ • . i < - ~ IMMEOIATE CAUS[ - - ~ DUE t0, 01t CO~+SEQ NCE O~. ~ A` ~ ' : W f.~~lilioRt. i( a~). r . ~ a wii[~ L~s• riit , l~l - - - iar~~list~ ~iiu ~+1. - ~ "~`7?~--- ~ tf/J~~s f~• r~1ir UUE Tp. O AS ' O E Of - ~ . , ~ lfi1~ ~~r~~ l~iY ' < % ~''~7~L~• ~ - - - ^ ~ F ~AtT u. OiME! S!Gn~f iuNT tOr+O~i~ONS ~ ewlrlior~ rorrr;~~i~s to dr..rb ~rr sor rdrr~J ro•+~re air~N rr t~+,+ 1•~+~I ~~~or5~ ~i rE5 a•nr JYrI+~d~ cor~t.lntt ! r)'i~ wol~ rr J~N?~iMirs c~r+rst o/ dt~/~ f , Z i~va--- jOe ~ E d ACGDENT. SU•CipE. HCM~UDE. DAiE Os ~WUer MOUR NOW ~N/U~Y OCNAREO ~l.,+~. ~ N..:H•t )MfL~I n. ~.r.~ 1 n• ?ol 1f. q~w In/ F OR UNCEfE~y~`+EO +)pr.r•.! ~.tl~.wtb. D+7. I"r.srl E E~ f ----`-1-iuc - _ - - rij iJ~i _ . _ . - - - - _.V. ~ ~ . ' t7 '~7 _--~~vo - , . INJUt~ AT YVOR[ i~lA<< Gf INIU~~ 1~ M~wr. WriR. Ihiff. /d.f...l. IOCAt10N I~r..rf K.l.t~ . u(~ N. ~iliajl. .7.U~. lM) y ~ 11( t1Ftt~~) N~ qo/ !,~1,~~~~~ `ldt.. ~h. ~~pn~~~I i a ~ ' i,t t > - ~ ; te+tn OCWtREC .~t rbe Ofi~r •r ~ CE~TifiGtlON- ~I•.w:/, 1)Jt I~rar .1lr~e:l. 1)a~ 1-rr. AND 1A5~ ~Aw MiM, HtY ~ O~U~ U~~ ~~S,~~A,~ . ~ ~Al1YEON ~ri[w T~tf~E'3L~rE{~~UUl) 16~ J~ft. r~. I~ ~ ' 1 AfTE~iOEG /H[ ~IO .?I..~tb 1)~~ 1 rwr . ~?ItR DEASH ~ ~bt ~ t II ~1 . . ` ' . ~ reu( ~i. 1ri fo - OCCEI1SE0 /RGM , Y ~ ~ 7~~ ~ ~7 ~ 11c_ ~S' ' '~d. ' 2t. M. lb~.~~~t1~J ~lsr~I. , • 1 - - - _L_ - - - - ~ <E~hf~U1iO+~- CG?(~*~f~ Uu tbr b~~i. u~ tb~ ta~~~~.~tin• Il.,~r .iJ d~~tb 1 b~ .l~~•JrN~ 4J. f~1. M:~ J: ..i /Irrr ~ pl `~j JMd~ 4I II~f II`{ f ll/~JIlOA. II~ 4`INI4/. 1If.1IL .IIfiM!~• I~.~1 ~ l~~ :.c~r.~~d •.w ~L~ d..t~ «~d ~:w~ t6t t+ris~il +r..fsd. , ~ :le. M. ~7b. _ K' . CE~i1RE~t-H4ME ~ 1 ~2s 'rt~riA!) SIGNATU ' ~ P<grrr ~n t~tlc_ OATE SIGNfO ` L h~ ~ ~R ~~b . r . , ~ rh_ - 3 2 f . , l~A+t~NG ADORESS-Z'E ,.R ' • STREET OR R.f.D. NO. C~ Ot V,?:aGE SiAiE 21~ BAY VILLAGE 4a. nN~O W~UI, ClEM/~7~Or~ UAf~ t+.~ME Of CEMfTERY Ot ClfMAiOf1 IOCATICN . itt~ ~~i~~~(~y? .•~rAI~ ~ 1~I.~III ~S rci~ i L _ ~~.ri 23 6 ' ~.~p3r_~l~~wn ~.e~io~_?~_ :~::_i_ __~~~'s_,~,`_Jirg~ d _ _ _ NAME Q~ EN~/~lM[f 1lIC. NO.) ~ fUNk ~ D~REC70R S 5'GN~Tu~F ~ ~UC. NO.) , J 7S _'t~ :,'"~T. D~~..11 1.1"1 F.~ 7-±~ 7A ~~~_.~1... ~ ~ r t ___~'_.,t__ _J~_~,. toEfl NO ;C~Tri ~STatE~ (I~~) ~ _ R ityJE~A~ fllK ANL I~OURESS ~S ~ 71 ~1f'n*~5.: .~~.1:'_'~~c'~.A .~,.~iyLf,_y~I: . ` a+::~.~:1~ -.a~11:.1..~ i.-.-• i~'...~~.-i-:.f:~4311V- 'l~~'ij.. ~ _ ' . . ~ D~It ?lflill[ ISSUtU ]fl.NAlu~l pF PttS.~N ~',~UIMU ~~~JMtI DI». l10. ~ . ~ ~ UI?if !tC D N (1'ft.~ :JjA~ S 5~4?~~IU f ~ . ~ / . , • ~ . r ~ la R~ / ~ _ ! a.+~La~. ~ ` ~fl ~ ' ^ .5 C )i / • ~ ~ Pc` . ~ O ~ l - ~0~~~3 fi~EO ~NG RECOROEO ~ iT.lUC1E COUNTY FLA. ROCER POITRAS CIERK CI~CUIt COURT ~ RECORD VEFi1F1E0 ~ oEC 30 ol aM •To ~ ~ 1QCROFII~i lS~~O Z,egibility of writing, typing r~ ~ BOOK 1~9 PAGE ~ ~c~ - nr printing unPatisfactory in this dacument ior !eicrofilming . ' ~x~ ~ , _ _ ~ , ~•~~~d.~..L