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HomeMy WebLinkAbout1105 . ~ ~ . ~ . _ . . ~ V ~ ~ / ~ • ~ :,~i`v:SInN ~ ~~U~3 ~ . _ - : st ~ Rt~d ~ n ~ t l. r•• D1li~IGT O~ COLV!lsIA DEPAIITllEN7 Ot PVDLZC N6ALTH ~.?1..uw2 ~ , rti-~icat~ y CERTI~ICATZ O~' DE11lH f.(. ~~1•7 ~ v rtfully N., s.s ea. i . ~uua ot D~AiID n.e x:+~a Z..r h. Dwrs u.,r~ D~ r.~. , s. !~S ~I D..1? - ; ~~n~• ~A BS1 ~ OWHiS p°ss'rn MA1~H l. 19?~ ~ ~ iitm of ~a- S6X 4 ~OLO UQ RACB Yewr 1l~rried. ~[vrid. . l DA7'S OF BIATH 1. ii~~t ?vtAN~r) wr ~ r+ ..n ~ onshculdb~ }~j Oct. 3, 1893 Y~~PPli~ PL.~CS OF DEA'eH IY Was6~q~~el1. D. C. f~ U3UAL ASBIDE.YC6 (MAe.v Jeew~ fiuJ. ;w~titwi.., n,ate.ss ~dor+ ~~TAaf6 OF H0.9PITAL.:NUR3INU f10M?L OR 07HSR INS'[1Ti1110N a. BtATB b- ~l1l~=1f ~Jwi~) ~ 1~ (Il wt i f iuitwi~w. N~e atrt~st ~t?ra) ' ~ e. y~ y e 1NSIDE C/7'Y L1111T8 ~hould b~ ~p(,'rpRS Il~S~jTAL Vashinaton 200pg c~leB ~FS oa ~o~ ~ w r i t!~ a ~ i. 9TR66"C AUptt~2i8 tU r•• ~•+p+) ~ ted in ~r• ~ ' 181 EYB ST. N. W~ i?1ASfi• D• C• Dero«shire l~l. H.N. type bl~ck t. l~~lTAf. O(.Y:UPAT101i (~:iar k~ r/ ~w.rk ~.w IN~. KINI) OV BUl31Nh'a8 Oli II. HIHTNPI.ACB It CIT1Zk:t U! NIIAT QOUNTNYt Jww rwd u/ wwk.p G/r. e~es d MreJ) INUU2RKY ~ (~fe w/wiripa rwt~i~ U.SA It t (io~t. ~'rint Off ~Ind. ~ F~TNBR'9 NAMB I~A. ~[OTHSRB MAIDE.~i NAMB !L NA~IS OR Si7RVIYINa 8l(W8E Alvin N. Ovene Martha J. Sullivan nune ,t' 1 Ever is U• 3_ 1~. 90CIAL BiDCU1t1TY NO. qa INF~ORIIAKT RtL!lIONdK/P ?+O' DSC~.I~LD q'e. ADDRfiSS Stiad CKf ~+u i , p~rmanlnl! : Foaea! no -60-1221 Miss L nn Crandall (Executri~t) same as above ~tord whtn + s i I!. CAOfi OT DL17'H~ (S~tar wl~r w~s ~a~us p Iiws !w ts), a~i ~ latenrd Bet~ce~ Oret z P~RT I. Dfi.~Tlf WA9 CAU86D BY: ' executed. l~tb[6DIATS CAt)SE l i-i~ ~.1. 1 Ir+.j~i,s ~t .e ~ i.3 t~.:-~ ~ i' Cw~l~tiow~, iJ a~r. / I ~ . ~ ~ - rA"rk N~ ri~s to DUB'PO (b) ~ 4t ( l.l•i.r ~ r~~I-~t~l/ 1~Ci i ~ i ~bort csws (a). st~t- a tt '!o submi! a uN r~e w~e,tri.~ c.wr 1 ' ' ;e of Death ~ ~u. DUS'PO (c - ' ~y ~ Deparlment ~ j lir Health r PART 1I. OTHER SIUJiIFICANT QOND1710VS: co~u~buli~ lo deat? M~t ~st l~a.. AU7Y2P8Y l 1~ It Ye~. Ne+e Fidi~pCa~r~ltnd ~ reiaced w tM term~ed cooy~.tw~ pr i~y.rt I(r) ' YES OR D~O ia Detecmaet Case ot Deat?? ; B houn af- ~ ~ t~ f- ~~'a 6s~ l 1~ C '!1 it 8~io- N 1P OPERAl'IOY RA3 p6A~OHatED lla. DA7E OF OPERATIO~I f~- OO~ID~770~? FOK wHlCli OPERATIO~I ~ ' f ihe laws ~ C'QbP4~7E ITE]ts 7a .sd ~ WAti PERk'ObtltED i ti. Uisfrie2 of V=!w. Rwcitr if .R:lat, wiciJe, Aww- ifb_ HOI;R AND DAT6 OP I~iJi•RY: 1[~rt~, D.r. Yav l1c• U£9CRIBS HOW 1N1UkY CC(?URRSD ' ~ d~ eide. or weoer urlMermmed (E~lei w~trrrs o/ 1+4~I u~ !bf / ae Rrt Il) ~'S ~ ~ : V l1.1_ 1\JItRY AT N'ORK_ tle. P4ACS OF 1\)URYc (At Howe, P~, l~ct~ry, !IL IACATION CITY C~UIINT1f STATE ; (Syecdlr Ysa or ~o) Jt?nt w O/ks BdJw. Btr.) 1~ ?ER W ~ I; ouT ~ n. ~«.w,? ~at m~~a+.-~..r~1d?.~e.ad~a s. a.~.o.a ero~ 1_- L~_ - _ n_l~ _,~.--3 ~~_?1_, s.~ w(.d ~.a = • ,,•t'HIS saw w/.o.o..a nn•• oa ----3--^i--------_ . H s}}_. o.i rss a.a+~ .cc.tr.e hM ~aw. .M a. a~.b oa a~v ~rua P?TAL" ~ ~ ?2a. SiGNAlOHL l2b. D.~T6 SIG~ED ! 3 A7'I'£~iDINO EDiCAL Al'AFF , ' j7' C Q t r PH\ ~3. UItiF(J'P~R PNYS_ 3"~'~" ~i ~ vf 16~sa !!c PHl'~IClA~i'!T , 1~ RFiYBi S'1'• N.W wASH • D~Ci ? - \AJ1E lT>pe) R ~AR~iZ H. • s •s s t= punisha3~1~ - . r isTipTtsoII- BURIAL ?~b. UA'1~ rir_ ~t~~lE Ok CF.afFTk:RY OR CRF.hiA'IiORY iil. IACATIU~I (Ci~/, to~r, ur rw.1t) t&~ta) ' 5c! 1:. CRti alATt~l)f ItE~lUVAL ~ 3/4/71 Gate of Haaven Silver SprinR, Md. ' tL FL'\ERAL HUaiF. r UYllE A1~EIt'3 /(i. ATUN ' lS.b_ L'~IUERTAKER:4 !t y~ ~6~E~i1 GAW[ EZ'~ S~i1S 111C. ~ ,~T ~ kF;41~TR~T10Y I AI~URF'_7.> 2001~ ,,~k. '{~~e ~ra~eF~ 0 Rtv.+ttx~: ` f11E0 ANO RECO~ ft~ \ ' ~ ROGE ~~UIT COURT ty %FHVS C.ERK C ' :v . . } i ~ s~ - ~ - . - - . _ '.'v ~ P?~ . ~ ) ~ ~ - ~ - :.Ys3~ _ , . ~ . . • "~,.i'.-~~ ~ t".n ~1-~. . ~.a . - 'j ~ . 1. •."~i~~l~~_ . i ; ~rCh 9 1 ; ~ " ~ A S t` t: ~ate f ssued: ' - - ' ~ ` NOT VAIiD ~ : . _ - : • yi ~ ~ . . . 4 TH 1 S I S TO CERT I fY 1'HAT THE ABOVE 15-/~TRUE ANQ~ C~ ~~EPRODfJG~101~" ~ - Of THf OR I G I NAL CERT I F f CATE F I LED 1 N ORDER MI ITt~- { "RCCi~R~,~ :::C , ~ DIVISION OF THE DEPARTMEN7 OF Hl1MAN RESOURCES; - - , . _ _ = !r _ _ ;1 ~ ~ ~ ~1~4 ohn ~H. ~Cr~rnda Ch i cf ~ ~~py 1a~ . V i te I Records D i v i s i~~ n