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HomeMy WebLinkAbout0507 ~ OH10 OEPARTMENT OF HEALTH '~~j~r~ r`~ R`s. ~O. DIVISION OF VITAL STA TICS s"`~ E~te ro. Prim~ry Rc~. D~u. :~io.~8$~ CERTIFICATE OF' DEATH Re6iunr•s ro, • DECEASED-NAME Fi.i~ .NiJdle L.ut SEX DATE OF 4EATH 1.11oar6, D.q, Yr.n1 Lee zi~letrric:~c ~le ~ 12-9-197C RACE a'b;rr, .r~.o, ~..~.~r~¦ AGE- L.~r uNoEe 1 rEAR UNOf! ~ ow~ DAtE Of {iRTH I.~loab, D•~, COUNTY OF DEATH i~.lu~. ur. ISO«i171 fi~tbJ+ l~u~i) .~1~r. D+ss Horrt .NiK. Z't~1 :~~ite ss. s~. a. q_1°ll ~a. T.~ic~s CIiY, WIUIGE, Ot IOCATlON Of DFATH 1l/SIDE CIi'I UM115 MOS~IUI OR OTXER IMSi1TUilON-NAME lIf ~of i~ rit6r?, jirt ~frttf ~~d ww~itr) (S1s~if) Y~s or ~o) ` ` / ~s ^oledo =es ~e. ~ 25S S, B}-,~-r;e Avt, =1 ~4C )^v ~ STATE Of ~iRiM !Ij wo! ir G~S..1., MJItt C~T~ZEN Of WHAY COYNiR~ MV1tRiEO, NEYER AuRt~ED, SU~V~VING S?OUSE !IJ u~ift, sit•t w~id~r rwatl terwtql W~DOWEO, OIYO~CED (S)rtij)) Fer.n~vlvan-~a o. i:.S.~. ,o. ::~rri~d i,. ~~ll^ Ann Sarns SOCtAI SECUl~ir NUM{ER Ww5 ~ECEASED EVER IM U. S. ARMED i0lCES~ ~ /Yn, we, ~r rr4rou~1 , il/ ~ri, lir~ uar er drfn o/ t~rrite) j . _ t~_.: ~ES~DENCE 120. ~ryC-n'~-r+M.i 12s. ir0 GECE4Si0 USWI OCN?ATtON IGit~ kiRd o/ uork dowe JrriRs Kou o/ RIND Oi WSIHESS OR INOUStRT ~ •E~ iF DfATM ~or4i~sliJi.n~~~Jrrt~r~d1 C~~C'vQiEO IN ~.5r~1:1f10N, GIVE l~o. a'OJ~ 3:~O~iE'•T'^ ~re5~~°2:~ i~s. 1.°f3 :'I. ,'il g~.J? C~" :t a15e0ni ~LE.'S ~_S ~Er.CE EEfOlE tESiDENCE-SiAtE COUNTr ClTll, YIILAGE OR lOtAi~ON INSI!!E GTY lIN!TS •~!.^.9f! l- ^!:J:A_°f •:M'SS.ON. ~ ry+ I S/r~i[> >tt soJ l/o. V:I_O tlb. L:!C:S lO~E'C~..O 14d. vQ~ ,1.. ~.2~~ ~~,rro _?,l, fAiME~--N~Mf Ft?it /Nildlt /If1 MOTNER-A4AIOEN NAME Flalf .1~1/dlf Vtt ' , IS. ~le~"`-e ~~i~ ~1~PT.,1(~ii 1e. 3er~ha £sasor. Z - INFORMANT-NAME MUUUliG ADORESS (Strsr~ os R.f.U. ~o., si~~ or sill~sq itutr, tr0) :'-rs. ~al~ ~ Ann :'ile:~rick »e. I255 S. ~yrne :ic? Avt.114~ ~o1Q~1o. O~~o ~}F1~ ~ lARi i. OEATH WAS CAUSED BY: iENiER ONIY ONE UUSf /Et tlNf f0[ (o?, f6/, ANO ld) ~?ROXIMA~E INIERVA[ ETW EN ?i Ei AN EATH Z ~IMMEDIAiE CAUSE (a ~ /I~.( . ~ L - . r ~ ~ ~ r~C~+! /"~.%jr ~ '-/7 C - _ ~ ' 04E TO, O~ AS A COt15EQUENCE Of: / C~eJitio~t. ~ , ~ ~ i ~r~icb s~rt iie te ~bl ~ • • i: + _t -L Z~ -fa ~ jL!?-~ !i--~-' i ~~-f 7~r-/-.~- " i~a~rtdiitt tirst /aJ, OUE i0, Ot AS A CO?~SEQUENt~ Of: ~ tt~ti~j tb~ rwlr?- ~ _ lii~~ stiul l~r! (c s ~ i _ /ART 11. OTNE! SiGNIf1UNT ~OND~TIONS.forJitiosi co~tribrti~j to de~tb jrt woe rtl~ft! to tar~t jirtr iw ?rrt l!~1 AUTOISII IF YES ~r~re F.J;~~i ~o~,rda.rd fY~i u so i+~ Jtltnwiwuj [+r~e oJ /~atb f 10a. n0 19b. ~ ACCIDENT, SUICIDE, NOMKiDE, DATE OF INri1R~ MOUR MOW INIURY OtCU[!ED /E~ler w~lrr~ oJ iwjrry i~ ~rr! 1~~ jsrt iltw 181 t.,~ Ot UNOEfERrainED /S~srr/~l IJIau6, Dr~, Yt.ri1 i i. 700. ' ~00. ?Ot. ]Od. ; INh1R'? AT WORK ~IACE OF IN)URY At bewt, j.n~, ihttt, ratto?~, IOCAiION /Shtet Or K.F.D. s~., tit) Or sill~j~, lttf~, :i)) IS)~ri/f )ii o. so1 o~icr 87ds.. err. ISy~ciJ~J TO~. ZOf 70a. /~1 ~ CERi~FICATION- .Nowrb D~~ Yto .Nostb U~~ }"i+~ ANO tw51 SAW_M~M/NER 1 D~D/DID NOT DEATM OCNRlEO At ~br OJartt e• ~ fMYSICIAN~ I1ltVE OH - VIEW T?IE ~ODY (N011~~ f41 1+tI, ~+W, f0 ; ~ t ATtfH0E0 iNf ' { TO ~ ~ Mo~lb D~~ Ytrr, AfiEt OEATN. ~JfL~•~rit o1 1y 1 ~ L / ~ ~ / ~ ~ ~ 1 , . I .k~oalid(t, lr~ io Iic. Cf~EASFf. F!~ j• ! L 2tp. ~ ~ic.: ~ .~y 'Id. _i:..~ • -!~l~rsrrt. i - CEtTlfIUTtOK--CORONER- O~ tbt b+iis ~j tbt t~uaiwuio~ l:vl• r; dr.+.:. i v s~ctot:.. u~+f yroaorwuJ d:+d ~ oj tbt ioJ~ .rcd: or !bt i~~ r.': jstrae, ic s~ oPi~ic+, st~l6 .Moub Dq Ytn Hlrr .~Gi- ~ 6:c+rrt2 0~ rnt ~i~ft sxl drr Io Ibt t~rtr(il italt/. - J2o. M. ]2s. _ ; CERi1FIER-NM~E /T~~s er ~ri+u) SIGNATU~lE / Drprr er litlt GATE StGHED ' ?aa. Dr. ?ic7?r~ F. f~ eh,•i.,a ~~s. l ,~_-f'"-`7~~" L `j` ~ D• n~ • -1 ^ - / i ~ MA~L~t+G ADDtEi~-CERt~f1ER 3TREFT QR ~.f.g. NO. CiTY OR VIItAGE STAiE :t? t „a 3~55 S12vania Avsnue . ioleco O~;o lij6?~ WR~Ai, Ctf~tAflOn OA1E NAME Of CExEiERY OR GEwtATORY IOCJ.t~ON (Cir~, r~!l~s;, or r~ru~1 (Stu•1 ~ rs~.~~~u ~ i , S; vania Ohio A ~:ir_a_ l2-12-?0 Toledo :'A:r.orizl : ~rt us. ~ _ - NAlME G EMIAIMER (ll~. NO.~ iVNEUI DI~ECTOCS SIGNATURE , ('IC. NO.i . ?s. Geoffre;~ ~Iar. =l~lls 6''7-A L,~t~-v.-,:! C~ ~G`~-~~:_l.~ 2~3 a a fUNE~I?l f~RIM ANO ADO[ESS (i.[EET NO.) (GTr) ~SiATE) ' ;;al'~c~r-? i b "rL•ne:al '.o:~e ~31 ;al~;~~?~-e 3~ Tol~:'o O~~o ~ 52'~ OATE ~EG~O ~r tf ISi~Ae~ S~G?+~ rE` ' / O~iE ?ERM~t ISSUED SiGN~tu~ ?E~SON ISSU~Nr ~Elu~~t 01ST. NO. ' t~GE 1 6 ~ '~r.// ~ ~ /C 21. ~ r. 1 ~ ` , ' ~i / B~GK ~ ~ r _ _ ~ r _ . ~ s ~~.:r« w_~~: