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HomeMy WebLinkAbout2500 ~ 2160'70 . .L(~~~ OFiiO DC~'ART1fi~N7' OF HEALTH . ~ NcK. UHI. ~iu. S~ale Filt ~o. DIVISION OF V{ i AL S i A i'ISTlGS ""~'Y~'}~~~`~~y I L'• PrimarY NcR. Uist. Nu._ ~ CERTIF3CAT~ OF DEATH N`~`~"`"•' ~J. r . OECEASED-NAME linf ~ ,~t, r/e - Lr,r ( ScX DA i 5 OF DEAThi r.~b~~.iL. IL~~. Y:~r) ~ R~~~G - ~ r _ i~ r~ ~ RACE t~'GIi~, MfF~1~ ~/!p%(IO AGE- Lnn Ut1D[R 1 ~EAR ~ UIvL1F~• AT ~~Te or i+~rn I.~IoN~b, u.~r~C I~KS~ DtAYH ~ irJir~. Ht. S~rcil)1 inlblw ~Ini/ )'~uI ~Nos. Dt~s llorra ~iiy. 'Q ~ j~. j' t0 Se. Se. ~ Sc. 6: ~u~: ~ 3?111 .~a ~2!f 1 ZO»a ~ GTY, VItIAGE, Of IOCATION Of OEAiM ~ IhS10E GTY ?IMI7S ~OSP1:Al OR OiMER INST~iUiION-NAME (I/ unf iw tilLcr. sirt Ni~t! r~~J ww~rLi i.~ ~ `s° ~aclid Gor,oral Hospit~ll ~ ~b L~clid ~Cos ;d. + STAiE Of ~I~TH (I/ woI ir US.A., wr~t UTIZEN Of WMAT COUNTlY MA~t~~ED, rrEV[R MARR~EO, SURV~Wt~G S~OUSE !U ~~if~, ~tl'f MJbItY NJp:~/ ~ ' ree.~nrl • WtOpWFO. DrvOitFO /Jp~ri/11 ' ~-Co~tst~~~.,10.~' o. J•S• ' ~o. :`~:riod CI.i«oz~u SOCMI SECUII~Tr NUM6ER WAS DEGEASE~ EVER ~N U. S. ARMED FOIICES? f 1'tr. ro, 1/ YML'MOM MI NO (I/ Yp. Cirt u•or er Jw/ti o/ inritN ~ „o_ 281-0 6 01 ~ ~b. , USUAI OCCUTATION lGira ti~d eJ u er41lere Jwrir~ roir oJ RINO OF WS~NESS OR INDU5~4Y u 'rtiMs !i/~, ~r~~ i/ r~tir~1/ (ri0~04r'l1AY' Tavern ~ ~OStSLL"A7Ij'. B~2' • „l ~ i~fS~OEnCE-SIA?E COUNTY GiY, V~~IAGE Ot IOGTIOn ~nS~OE C~i• UM~TS 5lIIEEi w?~O nUMUE¦ r~a«;Is r~f o, .o~ . ~,~e. Ohio Lake ,,._~~rillourhby „p_ vos (,,,.34755 Gr~t?a I.vo ' ~ ~ ~ -fATXEf-NAAIE 1`inf .~Ilddll L.it! ~ MOT?IE~-MA/OEN NAME fi~i! .tiii.l./!t 1r,: _ . Nezarrine Valocciii 16 IInk:la;m o ~ w~ `~`i- "INF a !?NT~NAME MAI~ihG ADLiESS fSfr[r! ai /Cd~.D. Na.. iily ur ~iJlaw[, N../~. i~p/ ~ ~~ord Behbvr~; i=usbind ,,,~7{•55 ova t:vo. ,.'illou~a~:~v 4:zio =;t;~.~qJ~ ~ . _ " - t" fise.-/f~RY~I. '-~y~~ - D~ATH WAS CAUSED QY: ifNfEf ONIY ON~ CAUSE IfR 11NE fOR tul, lol, ANJ tUl f ~'~v~~~.~~~e~ y . ~ 1~. . ~ 6E'N'l c~ C`n>~ : At~.1-- , W ~ UMM[0~ ~E • M ~+I~.M~ ? f ~,l / ^ ~ ~ I 'k~~ / G_.. ~ N~ ' OUE TO. O~ A CO EOUENCE OF ' U + Cerd tl~iijj ~l, ~/1. r / ~ ' ~ . :rbt pre eue ~ • ~ ~i ' ~1' ~ ~ V ( ~ v, :l~r Jj~ts•ssrtt l~1~ 1 _ t; U , OUE TO. O~ yS A CONSEQ~ ENCE Q f . ~ [ !~t ~rw~lei• ~ . ` • ~ c ~ ~ ~ E~~. \ ~ , _ ` .i ~f.~. ~ 4) vI ~ _ fl?~i •11.: OTME~ f1ONViGHT CONOITIOHS:(. f iow LINf/f~WlMS f0 dfMll! fIN! MOf /fIJItJ (O fJYft ~IVlM %M pI1( J(d/ ~ AUTOlSY ?:f Y~S u:~r /~.«:in~i .uw,f.l. ~:1 CJ . ~ (Ytt or ~~01~ ~N tIf(lIM/Mlqb irrit o! d...:u i too. ~ ltvo. ~ ' ACC~DEMT,~SIpGDE, NOMICIDE, DATE Oi INIURY NOYR jnOW Ih/utY OCCURREO (F~Id wlri~ o/ iN/ury ~r Pr~! 1 ai p+r! 11, ilt.r l.ii 2 OR-YNOiTE~NEO lSNriJ~1 f.No~b, Drr, Yts1 I a}: ~ a ,100. ~ : - 10e. 70c. M` ?Od. ~ iN l{ M I AT W OlK IIACE'Oi it+iultl A~ b~wa, Jir~, iUn1, Jrrl~ry, IOCAT~ON f~btN or N./~.U. wu., .if y or t•il1.~ Et, ~t.rtr. :ipl ~ ~°`.1$'w~h fei or r~l s~n ~/JS.. Na lS~rsill/ . ~ ~ ~y ?0+. 7M. 700. ~ CfR~f~U~~Oa- ,Nswlb }'~r. MowiL U+y 1'~ar !~NU ~~s: SAW ~~/M~A .Key~au H.~~ utlJ~MiJ ~~i.~:~. ~ /NTSIC~AN: ~ ~A?IVE ON V:t\V ihE SOOY1~~hOUK~ li~i .:./i, «u.l, 1 ATiENDEO TME ~`T 10 i .No.dL I)~~ Y~~r ~AfTER ~EATM. ! % 3,• h~j.t :-.r ~ . c:. . : • - " 74. DECfASEO fR0?+~ ~v( . ' ~ ' 710. f 7~ ~it. ~ f jJ ~~J ~ Zld. y ~ 75~. a~ ~M. !4! iruitUJ tt.+:a.. ~J CERTiF~UT10Y-CORONERv (JN /bf bw~i~ e/ IGt tsr~irrlie¦ /leri o/ Jt~t4 ~~~J( ~!![JfMl I!"dl /,fOMYMNCf~ Jf.~~/ _ o/ rbr b~/~ waJ/e. ti~;wreuis•ria~, IM Mr O(IIM/OM~ 1r+fb . ~ ~~~ON/~l udr ~~f.f/ /~YM/ e~crniJ e~ t~~ l~f~ ~~u11rt fe fb~ uwt(i1 ~f~ltl. I LL-' ~~e. M. , ~7~_? ' - - a; CE~i~i~ER-NAMf lY~rr ar .i I 1 r , S~GNATU4E l~r~~~~+,-~:U~ ~ uw~? S~Ge~~ ~ • ' ` ~ ]lo ~I~'1~ t ~1 4f ~ 71;r. 'i'~ ~ ~~Y7M ~ ~ 1 ~ 4 '+l. ~ r V aw~UnG wOOfE3S-CEfflflER J/ SIREEf f'^ .f f` C,i ~t`,~, GE ~ S1A1~ ~ jL 1.~. ~~:.:5. ~J ~U~~Ai ClEMAt10N, OAiE NAME Of CEMEfffY Ot CIEMAIORY ~ ~OCAi~Oh ((.i1), ri1l..~~, o~ ~orrU)I I~I~f~~ , 4. Uh~f(~I/ ~ :.surial ~,.~Jul 20 1 Rivorsidi inr~l j,.a ~'ainosvillo La::o o NAME 01 E?tMIMfR (IIC. NO.is• 1"U?.;~ l OICECTOR'S S GNAt qE (\IC. f.0.) ~ Jt?trios ~Tohnson b525 1• ' • ~ ' • 2:41 ~ ?s r I ~ j ! f_ . CL1/ _ 1 ~ {StATE ~ /U~+EfAt h~r ANO ADDtESS IS1iFEi NO.) (UTY ~ ~2;r; ~ ~p6a1' Funora.Y t~O~rp 111C. 6z $O• ~V•~-c. ~ir 7t• :A121~iV11.t0 l~l~A l;y{1 OATE REC"0 ~Y ~EGlbl~ f 1 AiY~E . J O~µ~T ISSuED S~GNATUeE Of /tASON ~SSU~vG /~ua~T~ ~ ~O~• '~EG I C~ ry r_~,_ O~ST. ~ ~ N~~9~ I}• ~ ' Q:'~~5~ ~~0 ~2~~ O1 /~i NJ,.~.Cd`~~. ~ ' ' ~ f~~co A~~ ~~co~~eo ft. WC~t ~?UMtr Fl?• ~ pOCEA ~ 0?.RAS CLERK G~hGUiT COU~T ~ RfC.OPD VFpi~~EO ~ SEr 21 I ~~Z aM ~ T I ~ aooK 1y5 ~rE z498 ~ 216U"~O ~ - _ ~t - _ _