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HomeMy WebLinkAbout2398 _ _ ~ . . • . Y ~ ~ ~ ; N.B. Do not Accept this coPY 1uilea~ ti:e raisQd soal ~f ~e Yonl~ers Depart,ment s ~ ~ of H~aZth is a2f'ixad thereon. y~ . ; ~ity of YankQrs~He~?York ~.3. to ~v~oi •acowoco o:s~s~cr NEW YORK STATE •~~*c ~~~c ~u..~c• r k~~-~=~~ DEPARTMENT OF MEALTH :~~:su~ sus- ~ On BUREAU OF VtTAL RECORDS - 4.~T a~~:~oN wcsurcw r...~~ CERTIFICATE OF DEATN TYPE ALL ENTRIES OR PRINT IN PERMANENT BLACK INK. 1• NA~E. F~R3T MIpO{aE• ~AST 2. a[a !A. O~~[ or OC~TM ~B. tiOU• ~~_-S'~T~~TI~AL piStA1~T i~j+J ~ w~~~ ~~MAI~ YOM~N p~V VCAII Y ~'~lA~ G AR£ T;,:•~±~ S A NO o ~ ~o 7a - '.a . . . . ~ 2 ~ M ~ q F c ~ , ~~CC (WNif[. h[GwO. R. •~C~ • ti OER 1'~~. ~~et~ / p? OA v[tC~/w Of y.l. ~~u[D fO~C[!• OB- 11 rLf- StfC!~v w~e..Or 4M[II~C4M ~NO~~W, [fC.l ~ ~TNf O~If :.k6y115 u~w. ~ DAT[i Of !(11vIC[ ' 'r~ 1 ' 1it//f/ / TF' lo~ : °'~t " ! l ~ ~ t~'•° . ; ,~s wo ,~RNO,~,M , ` E 5 O x^T~' ~ .Aa'~ 1~ ~ ? ~ ? ~ M 7A. COUMt• INYS~ 170. tOwM 1C. CITtl.OR~yijX~[ 7D. ~[hG7w os ST~~ ~y ~)E. MOS~1i~t O¦ Oiw[U iNSr~~~r~Op < 1 . j.•~~; "t- \ ici r., rt^~+ ~ rawr. c~~. ow vi~~~Gf~ t~~ NCI7NCR~ i~vE t~~EET .t . a. y w~5 : ~ fi' k~: o~v~'~,' ~7 •e-s- ; S 7,Ta.s'G~,o~ ~usp ~rA~ o ~ ` • c ~.sT~~c or e~wTw -Y"~!'~[peN'i ` - h~ii:p~'F.~y~? 1t. uaw~T~t s?~*us tt, su~v~v~wc sous[ ur wl/[. MA~OCM r.wc. ` (COUMTNY,I~NOTUS? IdOMTM O Y _ '.'t,"QVMt~~. , . ~c' QE SA~D 't'e j~ '1XB. . ~yI/~ Q~E~ ~qLf .D T p~ :'L. ~ .7.~ 'f~Y"° t3A USUAL OCCUO~TIOM (CV[N li 11[TIA<Q) r., , • 13g- RiNO O~ ~~51~tClS 0~1 ~NOYSIRV ( I~C. SOC~AL 5[C~111T• MO. / ~ ~ ~ /joc ~c~w~ ~e ~ .~al?ie ;Dy7- /5~-37oG .e.R~ wElID~MC[ wresa t ~SLD L/Y[O. If ~ ~~A, iTA~E ' ~~8. COUNT? ` 1~~. TOYrM ~ 1{Q. C:~• OA ~~IIAGE 14E. WtTNIM TME ~<F_ ST11[[T ANO M'Ny~E• - ' GCCN~111[O IM '.:T~OM, i1VC ¦[!1- ' ~ COwP0~/~T[ lIw1TS) ~ cc •ero~[ ~or~~SS~ow. ~/Y~1•(/ ~ Vf/'ES 1 `/Q/LK~t Q ~ ~ res ro i f 9z L~.I~~t'.t~ Jj ~ i Ok ~ i ~ _ ? R ~~A. /ATN~11'S N~ME'. ISB, MOTME4'S MAIO[N 44ME'. ~ F111ST M1DDL[ LAfT s•q5T MIOOIC ~AS• ; ? 0~ ~v L_~. ~/,Q oL 7 c Ss .,E ~ a c~C HM oo.ny ATTQITION 14A. IMtOAMAM7'S N~ME: 'IOB. uAillM(~ ~DDI~[SS 1~NClJO[ :~V CODE~ F~~. E~~IDII I! MOT[D ~M ~ /j LF/C E~/ ~IS~Y'~n I _ .c~• ~.c.TC~crowt~ccco- ~ ~~;1 L-/H:)6Q/ .S / ~~o~v.~E4~ = F er O[G~3711A11 ? [O~1- ~ >[;'fC CEIITIIICAT[Ia~~ ~E es=~,_~co. P~RT 1. O[ATq 11VA3 G~U3[O [MTCA O'.l? O~[ Ct~,J3E oER t:w[ iOR ~A%_ iB), 4ND 1C/. AOOI~D~~4~TC :At(I~~~L •ETWEEM QMS[• S O[ATM ' « !HCOR11[CT CIR71I1- I7. ~Iy4ED1~T[ CAY![ -~*E ~~3 •[[N •CC[~~EO R• •^C •EGIS~R~R, IIL[ iAl R C~ ~ ~ ~ C-H ~ N ~ ~ ~;•v V,S, 6{_ DuE •O O~ •S 4 CONS[pYEwC O~ . COM0IT~ONS. ~M~, YVMI~M C 7tr /~j ( 4AVE 1~~SC TO .MMED. ~T[ f B~ Q ~ O J ~'~~T~ C_ l.. ~ I iJ I~+~~3 ~ S CaulE IA~ S7~s~y~ ih~ rwD[wt~ ~wG C~~3[ ~aST TO Ow I~! A CONf[OULwt[ Of tCl PART I1. 07.~E¦ SIGMifIC~MT COM0~710MS. COMOI~iOMi COtiTw.~u~ING TO 1lA. •uTOO3r~ I~B. tirES.ME1~CfING~MGS COMSI~[~ED 1M ~ OEATM •JT «OT •EIATED TO CW3[ G~v[M ~M •~wr t~,4~ •ES ti0 ~ DCTERMIMIMC TNE C~uSE O• DEATAT i Z M I r[S w0 ~ :i. ~ 1 1 2 F . _ _ _ _ _ _ . . 1 t 1pA ACC:DEMT. NOM~C~O[ ~t98_ MOK7w 0~1~rE~• /C r.O~i1 1Dp .+Ow O~D ~M,VN\ OCCU11• t~KT[11 N/~TYwE Qf INlV~IES IN ~17 1, 0~1 ~1.~ V SU~C~O[, uMO[~E~uw[D I ; 1 1 ~ ~ ~ :9A. ~ ' ~ I9E. ~Mtvwr •T tiORR• lY~, •LACE Of ~M~uwr. Mor+[. 19G. iOC~TiOM IS~AEET 6 NO., CIT~ O• V1LlAGE, T0111~M, CJUMT~, STATEI ¢ ?U NO 1 f~CTO~`/. OIhCE ~~OG., ETC. ~ i~V. U Q 1 1 i TO BE COMIPLETED BY -0R_ TO BE COMPLETED BY 20. PART ~ CERTiFY1NG PHYSIGAN ONLY' zo PART ~ER OR MEDICAL EXAIAINER ONLY w A,TO TME •ES~ Ot~Mr RMOKIEOG[, D[ATM OtCYAREO A• ON T~.E l~5~5 Or [~4M+NAi~pM .WD/OR ~NYES~~GAT~OM. iN M~ ~ TM[ T~M /DI1r[ MD PL~CC AMD OYE TO 1NE uOMTN DA? ~[/111 Oa~N10M D[4TH OCCYMI~ED •T TME ~~ME, OATE ANO iIAC[ ANO CAUSES TE ~ DuE 70 TME [wuS[5 SiAT[D_ ~ ' ~ ~.s s,~~E • /a / 70 ~ ~ S~GtiED.......... . TITLE........... B. TN[ o Y ICI •TT[MO[O tNE O[CEASEO C. L~.ST SEEN ALIV[ B. PRONOJNC[O DE~O C. NOU11 D. O~TE S:GVE~ ~ ai " Q o~r rE~~ MOMTM ow~ •ue uowt~ oa. ?caw 40NTN oar re~w n.oarh o~? r~~~ ~ ' ~ ; / \ ' ~ ~ ~ t O .R~ i110M: / ~ ~ • ~ ?O: ~O 1 . 7v . 7(,_ 6M ~ 47 ir. ~ ~rav - VSF-F-p ~ D_ ATTEMDING PM~SICIItM, 1/ OTMER TMAN CE4T1I'fER: E.' 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