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HomeMy WebLinkAbout2714 , ~ :sci,oa• o~s:.~:; - NEw YOAn ~TA~~t •.~ra n~c .w..• ~ DEPARTYENT OF MEALTM ~ ~~5(~ BUREAU OF VITAI. RECOROS ~ .S aviioH CERTIFICATE OF DEATH '~'-i"2-~~-~.) _ i~-rn _5 _ TYPE /1LL ENTRIES OR PRINY IN PERMANENT BLACK INK. _ 1,1J 1. NAME F~RST MIQPLE IAST 2. ~(R ~A. OA~f OI O~ATN ~0. wOr~ ' ~ w.a~c r[u~~[ .~o~~w o~~ ? ~ l~ c+ j~q( •.c~~ o~s,~~c~ ~ ( ~ / . J ~1- / - ~ .!C"1'(J ~/~~U~,.. 'i , _ - ~ - ' ~ e a. 11~c[r 1ww~TC. wfcwo. •6c ~wctw 1.e ~r owo[• 1 0~: !w .cfcww o• u.s. •~uco rosc[a' 1~8. v[s-s~talr w~A. o~ ~i.__ ~u[w~Cw ~wo+l?v. art.l 4otirws D~.a woup-~?~iw ~ O~tCf 01 ~l~~~Ct / / ~ ; ?fS NO Uf+ANOM'N ' . t y~~i r~_ F- ~ p p ~ V 7A. Co .M~r tNVS~ ~ 7B. tO~v? , 7C. t~r~ Ow ?~~l~C[ ~ 7D. LE~Gr.~ Or sTa• ~N ~7E. Mo~P~ r~~ 0~1 orwt• t!~s11~vT10M M ' TONN. C~~~ OAV~II~G[ llf \CIiwCA~ GIY[ ST11[[T ~10.1 < . , ' ' ' D - - ~ ~ ~ ~~~~~~C/Yf ~ /i~'l~.rr-r N ~ ~S'~ ~s T ~QLoell( ~ • ~ o ~ l.si~T[ O? •~Ata O. ott[o[rt sOAr 10 Ui~t[N O? 11~«AT 11. N~A.u~ STwr..S i2. s~Ariv~MG 3?OViC III MI?t. YNOtM w~u~.l 1COvYTA~.:f\OTl~1• \~O\ir U~~ ?[~A_ COJN~A~• ~ ~ . 4 : z ~ ~ ~ ~ v S. A ~/~i R ~i l ~Q ~ ~ y'~r ~'~~i'R Ms ' 17A. _s.~l OCCUP~~IOV l[Y[N ~r ec~:~[o~ S 138. w~.~o os ws~w:ss ow ~pousrw• 1 I~C. foCiAL f[tulntt ~O- ~ u 1 . ~ r . ecs~se¦cs wMUC C~~~~ ~ / t• Q C/ C c N~•G L- ~ Q~J ' ZO-~ ~2- ~ r ~y{~'~ r(O. 1• 1~A. STAt[ 11f,~. CC~rIY It~. 1JMN ' ~ 1{~. C~1~ OA YILIAGC I~Q, wITNIN TN[ ~~F. STA((T ~MO MYY~C• ~ OCt~to ~w ~ I ~ I t co~vos~TC uuiTS! I ~ .+rY•o~~ ~nc sil~. ~ i • . pc~ [ ?or.~ss~.ov. ~ • . 1 ~ • c wo ~ ~ fid cRf' ; ~r ~ H!sy~Ai~ , lrR~' ' o ~ 3U ~P ~t~r/.(~~. p 1SA. /~iw[A'S YAV[' iSB. YOTM[q'S ?RA~O[~1 NA/J[: . ~ s~ws~ .~~oo~c ~~sT s,~sT ..~oo~c awsT ~ ~i 7 / I f~ ~~~1 ~ ~ ~ ~ /r L ~ ~ ATTENTION 16A. 1f~tOA~•/h~~5 \~vE-`, ~ 16B. u~II~N~Q 011[S3~ l~pCIJO[ 2 COD[~ ! . I ~ J ~ ~ ~ Eno.¦ ~3 MOT[O IN • ' ' '[I . . .•c ~cro~[ ~tcc?- ~ A ~ ~/"J~ ~ls~ ' T ! , : r. .,rc~sr~u ~ to~. ~_~Z~_' % L` L~161/ aCr{_ ~~~!~I1CAT(YAr~[ .a!"'.'LD. - A~~AO~/YATC INi[~1vAt PAR I. OC~TH wAS Ul3[D S• [niEw JwU D~C C~vS[ oE~ a.iv[ i0~ t~~, IB~, «D IC1. •[TVr[Cw ONl~T ~ O[~~w ' l[ +~,C~A[CT C[ATI/I~ 17. ~WUL9IAT[ CAuSE ~ ' . •[tf~ ~CC[~T[D • . ~L ~ • y~ J.~ . `aEG~ST11Aw, •Il~ l.Ai ~~L/y, f/ ~ ? {."~~L~'Z.i~^~Zt 7 _ _ v •.S. e4. ^_f •O OA •5 • COVSEOUE~tCE Of ' CCNG~T:O\S, ti AYY, Nw:Cti V ~ GAV[ 1113[ '+•MED1l1T[ . g: ~ . C4YSE lA~ ST/~1.~.G TM[ VMOEAL~~VG C~JS[ I~ST D:( ~O OM •5 ~ CO!45CQJE\CL O~ ~ ~ PART 11. 07H[• S~4A~i1C~V~ L0~1D~T~OM3 COXD~T~O~IS CO~ITA.O~T:NG T~ IE~. ~JTOPSV~ ~IdB. 1~'~(S.wrCw[r~xo~M~3 COrs~OCOCO :v ~ O[~TH •JT rOT NEI~T[D 70 C~USE G~vEN :h >~N~ ~ f A~ •[5 w0 ~ OiTEAr+~MING rMC CYI![ O~ OCATM~ Z ~ , •[s ~ wo ~ O ~ z • ~ . - - ' ' r t I~IA •CC:D[~T ~+Ou~C•DE. ~~~B MJ~T~~[~~? ~EA11 f0~, HOUII 19D. wO+v D~O ~Niu~• OCC'JA~ '[VTE11 MATUAC O~ rM~Y~1~[3 IN ~17 1. 0A ' V Su~UC[: ~nCUCR~uihED ! ~ ~~A 4 ~ ~ ~ M _ ; ' ' ~ 1VE. ~wi~~r wOAw~ 1DF. C~ACE Cf :tis~NY_ ~.OUE, • 19G. LOC4TiON 15T11ECT • MO-. C~?1 OA YI~LAGE. T01~M. COYNTt, ST4TE7 ~ ~ a ?[S v0 ~ ~~CTCO~. O~~iCE •ICG.. ETC. ~ ` ~ ~ ~ ~ ~ ~5u u ; TO BE COMPLETE~ BY _pR_ TO BE COlNPlETEO BY ~ ~ u CERTIFYING PHYSICIAN ONIY CORONER OR MEDICAL EXAMWER ONLY • I 20. PART ~ ~ 20 PART 11 ; 0•.TO T.~E lEST O~ M? •f~uM~EUGE :E~T`r OCC~.AACO •T A. OV inf !~5•5 OF E~~w:w~!~ON ~VD/OF INVES7IG~TION. ~N A~1 `~.E T~~vE,. AT( wD ~~a[F •~C :~.E r0 TwE ~yp~,~w D~? ~[a11 Oo...~pr. DE~i.. OCC~A~ED •i T.~( riME. O~i[ IUID PLAC[ ~NO ~ ~ ~ . D~.E TO Tr.E C~:~SES ST~T[:. C~~S[S Sf~iT[O • ~ / ~ ~ ~ ~ ; ~ . . . ~ : 4 , . . ~r,., ; ~ S~GtiED"""' TITIt......_........... ~ S~Gw[D.. . ,.~~.h. ? B. Tr~E vM ~C~~w •TiEI.OEq T11[ DE[[ASEO C. LAST SEIti •l~vE B_ VRG~OUMCEO DE~D C- .~.vA O. DaTE SIGN[D I ~f~Tw DA~ [AA MOATti DA~ ?EZO NOAT.~ C~f •(iR MOYTN D~T ?EAN MOMTN OAr r[~w ~ _ 1 1" ~ t ~ T N. ill0bt ~ t0 1 1' ~ I I I ~ f, l° JN 1 ' A ~ . . t __1_` 1 ~J~ ~ ~ ~ ~ ~ . j O. •TTE~t~rtiG on~S~C'AN. if oTHEA ?~14Y CEAT~F~Ew f E_ CORONEN"5 ow~c.C:1ly. ~.i OtMEw in.W CEAt1/1[A: , ~ l ~ ZI. IY~M£ ~~ID ADDAC55 Of CENT~i~Eq ~PM~SIC~~Y, COMOYEA, M[O~GAL E~AM!~EA, COAO~i[R~5 vtii5~[~U+, w~ED~t~I O~IEGYOA~_ _ ~ 1 ~ • ~ . . ~ . ' ' ~ /1 I i 'd - - ~ I i~ ~ • i i ~ . i-i i ' '~i • i• - - ~ ' _ y i~ ~ 22• O.;A:~l CAE~• ~OY A[~.r0~'~~ uOMiM OA~ rE~R ZZB. Pl1CE ~f iJA~AI. MAT.O~Y OA ACMO~AL' 22 *tl ~~'f~f~~~. S T~ • D C , ~o ~ ~~N~7o ' s~ . 23A_ •auE •eDw[s5 Oi s~.~V[RAL MoMt ~ • - ~.M6L~T~A~IOr w0 , J ~ . - ~ ^ j--~y-1~~ < < t• ~F .iYr 2~t Ir N T, T' . ~-~--i/ ~~j.~ t c ~ t L• a 24w. t~~r.r[ O• r„~[~K O~sECTO~ 24B,~iKti~T~w[ Or NCf w~ii~ •A1~0~ ~O f ~ ~ ~'ir N ; _ ~ J.(l.~jY,<.l!.t.~~ ~ ~ 'Q ~ D ~ _ . v ZS•. s:cv~r,:¦[ or ¦[4tST1~~R " 2SB. MONTM o~r ?t~~ :6w. W~u~ ow ~c.nov~a vc~~f ~~y~,6 ~M Ylrf~ O~r it~w ~ o•rt . _ • - ' ' -1 J . _ . . . . ~ . r : u n 1 ~Z4 '1 p . . _ . _ J'Q.V.1.~t^,AA~ ~ , ~ ~ G L~~ ~~~r F~~EO R±+~ aecoRO~a st aoc'Ea~FO~ai?s~A. C~ERR C«~~~T COU~T AEC4p~ ~EAtF1E0 t~ _ J~ IZ 3 0l PN'11 ~ - g~;K ly3 2711 - -