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Home My WebLink About2976 T ~ ~~U539 HVSlO10! lpw.l-1l011-3~34 ~~'10 , ` ~r~. ta. ~ai. ~ ~ N~ J~~Zy7 c•.n~n~.~.. t~.oo? . Thls to CetLU7 tlut i~ tbiio~ypt 4~ irus a~d correct oopy of ~ ar~b ot de~th tikd ia tM D1rlaioa" Qt W0~1:~~ l1iO~qlvaal~ Oeputment of Henlth. u dlrectad ~ by J A N,~~ - F~~'°~ L' . . ~ ~ , , ~ ~ ~ . - . . - - . _ ts~+K.~ .e e.~ui - ~ . ~ ; , , . oowroMwu~n~ oF ~cwNmv~i~ FlN N.. ~~n ~ ro 0_ ~ • OitARTYEMT OR I~A~TM I~I~ry ' OIVIi1pN Of VITA~ iTATliTlp oiN ~ CBKTIFICATT OF DEAT$ (o . . ~M+~ M~ 1. PU1CE OF OEAT r`. UiUAL 11Ei1 I~iw~ dK~Y~A U~ed. 1( trdltitio~: wMi~e~ ~aw a Cerwtr a i1~M Cw~b d~Yioa) f. Clty (If o0 oayaf ib. ~rti DItAL a~d 1, L~tA M~p) dty ( U ortddr eoqa~b li~fy ~trih tULL te~rld~1 iowt~AiV) ~ (i~ eLL Nrcel ~w • F~II Na~ u.oe ~ Ia•W~ ar iuuoe. ~?.e wee.e or L i~r.~t pt ~l. s~. 1ovt+~.) ~ W N j ANrNt . ~.IT1nt1 0.lriWdlt) (LR) I 4. ~ a~ti) (Dq) lir,r) w Aiwt) OEATfI EEX i. COIOR N YARRIEO. NEVER MAMIE~, R O TE Oi tiRTli ! A9[ ( N UM~r 1 Y~~ q YaMr7~ MeL WI 01NEO.OIYOp~.EQlBOee~f) Irt )Illo~td~ DRp Bwf~ I Yfa si.2=Zi.~ lOs. UiUAI P~ATtlON IOI~e kfad 10~. KiND CF ~Ui1NE53 O!1 11. !IR CE ( Ri~ 84te o taeelp e~ortr~) 1!. qTIZEII Of ~.p ~«v~~'fL~ d ~wti~lt Ilte. e INUSTRY • Wllll NTRYt l a~ZTlt ~s~ it ~etlnd l ~l l~. FATMER'S NAM 11. IDEN ME ~~LL1t~~~A[~_ ' 1S. M?AS DECEA8E0 EVER IN U.B. ARNED li. ~OCIAL aECYRITY T. 1 T'i j{M[ Ap01Kis ~ FORCE,d1 (Yet wo a~ ~(lt le~, ou~plete er- YOkaO~w ~ene aidr ot tRLlAcitr - r 1R CIIUSE M OEATM ~pI CATIOAI . ~MTENVAL ~~tww ~ i~11et od~ a~a ca~re L 018EA$E OR COMDITION ~ ~ ' OM Y O[AT11 v~* ~fee 1a ~~1• (D)• DIRECTLY LEAOINA TO DEATH• and (c1 ANTECEOEMT G?UEE~ ~ ' ~ihir dob wot YorMd cowditiow/. if aw. WE TO " w~ow d?e +wod~ of dof~0 rlat to tJ?~ ~Dove ; d~ ~ pdsr~rb o ~es ~tlls yw ~ ~ ~ ~ /1 . ~ a-v,~ 0'Ca'rv ~ tte. It wNSy Htt D TO N d ~t~• ~ 11 OTNER EIQi11FICAMT CONDITI ,,1l, ~t ~cw~ s~ vAitk Cowditbw~ cowMMttN~Y W tl~s i~atA brt wot ~ ~ t"""~`~ - ~ ret~t~d to t7K d~arars or co~ditlow d~sfi 19L DATE OF OP- 1!?. MA.IOR Fii1DINOb OF O~f.MT10M !D. AUTO~Yf ~ ERATION YM t'1. ~ ~ L!7 E 21~, ACCIDEMT (SOecY~) ~ 21r. PLACE Of tNJURY (t.t.. i~ at ~ l~i. (dTY. TOWN AND tG~N1N~lIlr) (COUNTY) tiTATR~ ~ E111CIDE a0ort ?oese. i~. f~c~tcrf. ~treet. FIOYICIDE oAo~ bldR.. etal " 21~. T111E plmt!) I~s) IYarr) Hoor 21~. IM~1tlRY OCCURREO ~11. 110M DIO IM,IURY OCCURf I URY s. SB.T. ( Ww# W~rkh 0~ s 22. I kereMl ee+tiiv tAot i sttewd~d tAe dec~aai }?o~w 7l....../,~to If......, tA~t 1 iyt aw tAt irewNd R slioe aw 1!-...-.. swd tllat d~stl? oeetinrti at .....l.37...w SS.T.. l+~ww t1~e cswes ad ow tJ1e dstt ws0~d sMoa ~ ~ ~ 51(iMATURE M.D.rMFI ?J~. AODRESi ~ . I? ~IED ~ 6 6 ~ w. BURIAL, CREMIt• ~IE Oi CEYET OR IM Y l~N. TI (!'c~. ta~~if~ ud oooatyl (~y~ T~ RE1qVAl • /'Y i 1 v ~ TE RECD Yf LOCAL EAIBTRAR's A b1ANATU FUNERAI DIRECTOR /1D~ < ~ - REQ r ~ . _ ~ • n. Z~ A I i ~ ; s' . f~~ fG +L ft ~~Cah~ RE~ ? ~l Rd~t n p~UMTr ~ED 3 RfCOq~~'~ ~~q~~~ TR,~a / oE.L' ~~~~'f~EDT ~~~Rt~ ~ta.`{ - F~R~1~7 ~~.~E2~71 ~ 9s6~ ~ : . ~ ~i _ ~,~os3 . ~ ~ . : _