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HomeMy WebLinkAbout0592 ~ CONNECTICUT STATE DEPARTMBNT OF HEALTH ~ j~ i q ~ ~T ~re~r o/ Vital $t~tl~tic~-H~reford. Conn~etieat, U. A. • - ~O • y . ~ %~E 1~L~H ~ ~ _ , . . - ~~c,~ ~ CertiFeeate of Ihath i _ - - - - :.,,c,. os . f~l Stab ot Co~~actfe~t Vsv~~ Rnroat+cs o? Dece~n~: h) sua Conne~ieut~egal F i El.~ (Dl GuntY` ft) 'N~w ' l!) Count~ le) 'ibwn (d) fs Rnid~ne~,~~~ New• Haven ~ New Haven New Haven I New Haven •c;ti ~°~Te ~a~,yT ~ (dl 2`sme ot HwD~td or Institutioa (e1 Sereet Number 1ln ~ No IJ ' ~ IIt not in • Awpiul or Iwtiwlbn ~iw Street Na tlf nra~ tiw beatloo) Tt Yes, aam~ C~tr or ; or bcationl HorouY6 ~ ;race-h'e•~r Naven Comm. Ho it 1 Cotta e St. (q New ~•aven ~ ? i. N+ws or 'intl F~ ( i~Wk1 J t! N 4 Sotub S[tvamt `uM~u Pccswsro ~ (TY~ or Drintl _ ~ 6-3025 _ M ; MEUICAL CERTIF K ~ ~ : ~ PERSONAL AND STAT1STiCAL T TI S n. C~ a o? Dennt [Lwt~~ ~w1~ ~n~ ~a' ~ I ~?~?!`...;ilfe) ~nd(t) ' S. S[= C. iL~cs ,,.•••e•-. ~ ~~rewv~~ ~ 'I. MARt[m ~ NRLt MAWm ? PARt 1. DCATH wAl CAV~O H~Z ' j . ~ETn•ECN ~ ~.a ~ e ~ Y~ n 1 li P alIDO~?tD ~ (jlrpqm ~ ! ~NM[Dl ~da / ON.~D[~wT [NO ~ ~ . § ir ?I~R~aa W~oorrso oa Dno~cso~ a~s Ywtesr Nwrs o? ~ u den K irs oa Hv~wxo HA ~ ~ S Ann r,arino - ~ 9. DwTS o? (~onth) 1Dar1 aYear/ Dv[ TO (D - . Dewra L CondiUoru. ~2'~OYO "'93A~a' • > October 22 19v4_ I i[ ~n~, whkD = r lo. D~r~ o? B~arN /1es (io ~crn It undcr 1 re~* under 1 d~~ ~~~f •Eo?e eause last WrtlWas) Yoatd Da~ Haors Mins. (~1. ~t~tin~ ~ ~V October 4, I I ~e. n~aRa• n~~ W. 1917 4, . ~ ~t . , - 11. BIRtH?LAR (Citr or bwn) tStstr or (orriso countnl 1 PART II OTH[t .S~GNVI~ANT CONWTIONS COtITi1~U71N6 ~ 23. S 1 ~ I~rew Haven, Conn. T~ ~ATN •U[ KOT RtLATSD TO TMt ~tM[NAL DtiiAEt~ ~L"G~SY ~ CONqTpN Gt~N IM Pw~T I~~1. r p~RroR t2. (~l liso~~ Occur~rwr (Gi~e kind ot ~ork done durfo~ most o! ~Y~ workiot life e.ee it retindl ~ 1 ?-q~ Plumber z.. s.~.~u. R[L[~'wNT co«~r. ~K ~nK _2. 1~1 N~me o( operation ~(D) Date (b1 l~n~si a ll•~. csa D=rlormed ~ ~~oc`~t~.nger Pl~~mh.,~~ !r ; 13. tal w•s Dece,?un ~ Vetsu~+i Ya or No ij ~ tb) T~w~ cr I~c~oar (bl i! ra. Civ~ war w. 11 I) 28. lal AcctatKi Svtctnt Hoy~acs ~ Nor. 1~low~k. Aar. 1'car :`=3 L.'nit or~Sbia 1? _ S ~A2'~Y1P_S ~I ? `~.7 ? i m. - . = I{. tiA?fE~ ~ v ~S epjl GeS 1nQ _ ~(cl Is+i~att Occcauo Id? Plwft O! INJL'tY (~.p.. iw o. a6uti~ i.o.~u, _ - lGty or tornl (SUte or torc~an eouncr~l ~I Whik at 2Jot Khile lulory, ~t.~~t, o~fc~ b:dp., ~te.) ~s " < 1S. IItar~~ruc[ Ca$tile~ara Di Stabia yt$1~' N'ork ~ at Work ~ .~~A7DC`I ~el Cm. Tovrx, OR ~.CCATSOY COUN7Y SSAT[ ,6.:~„«~ Carmela Ferrioulo ,i i (Cit~ or town) tSutt or [ure~~n eovnlry) ` ' ° T+ ((1 D[acR:~c H~w SH~uar Occua~sn. 17. 132Fttft~wCt ~astla~ra ra Di Stabia l l~a /E*~~~ wntr?~ oJ iwjwry iw P~?t ! lg, jxruxxwHYS Nwlrs j o~ P~•t 1I ol titnw !t.) l'-T~S . Ann Gesino ~ 1~•ife) 2~• ~ HEREBY CERTIFY, a t~it d'~ oa~X f _ ~ L,. ~ X T X Z?1~ _~t~ Y T T T Y T M Y'S ' 19. Bv~iwt.. A~RlM?}Mit~'w~i D~tt.~C.t- ? ~Fi 19~1Y ; - - ~ c~meteq• ~er-Rrwn~l~k f,~ t.r rp„n r[~ e m r~t ~ Z~,t17G.~7G.~iC~~ eT.~aT.d11~Z 31 _ _ Fi~cc;~P. $~i }'y~_,,~, C..On tAat d~ath f~ uid b 4a~f oeeurred on b~ ' 2J. ~wwa or F.n~wua=t t? Haotr swi nMUns Lieeew nuo~b~ ie a. ~ :.ouis . Lon b rdl ( 148~_i z7. S' ATU~ o. r~.?~~ 1 „ ~ . , . .4,•~ ; 21. Sccvs: M uit~ oa ste P IhasCZOa ~ • i" ' ' '~10T'~ v OnTi., ! ~ ! ~ ,;?:r~~ °I' • ' ~ae. - c' D ~ THlb CERTIFICA?~ $LCE1 !'O 1lLO01tD ON I~* T T% , October 26; 1964 - goRx va.~ ci-s» :s~t ! ccrtify that t6i. i• • tra• tr a~cript eE t6~ ieform~tion oa the de~t6 r~cord a~ r~cord~d in t6is og'ic~. ? , I h, q;-~ 1 t Atte•t: . . ~~w.a..t... ~e~i~lr~r ~of Vibl $t~tisli,s ' :J~t~d ....~1!'fCtiC.~PI' ~7- 1964 ~ , ~ •,~Tito ..................i...............................T.... •f......... k6L....;.,.'SL < • N 51 IUCt. • • -s : }+?R?S ,~t NOT GOOU WITNOUT SEAL OF CERTIFYING OFFICf~1L pG~:~ . •:n ~'ti iSl `.L~Sill . ../.i~~~ C.~VR~ ~ ' pEC~~=~ ~r ~~E~~ ` o~; e io ~9 aM'j i g ia,-~ t ~ , ~ ~ : 5~ zise;~~ ~ i