HomeMy WebLinkAbout2772 un~i a~vnn 4i i i tlC.t~Llli u~r-,~ni~r~~n t ~
QUREAU OF VITAL RECORUS ,
[ORI)ER N0. ~J l~~ 2~244~1 ~ '
• ~
, ~ > _ dA1TIMORE C1TY HEALTK DEPARTAIENT % ~ • . ~ ' • ;
- ~~JU • . , , . L;
~ o s B1R1H k~ ~ ~ _ : ~ -t.• CERTIFICAT~ OF DEATH REG. NO. _
~
O i f ~ I,NdlME Of E EA ~ ~ , DATE ANO MOUT~OF OEAiH ~
~ r O N (t~ye r.nu ~ . ~ ~ • ~ ~ , -...r.• ,
-O "7i v , , . ~ ? ! _ / / . ~ ~ ~ ~ ~ \ : - ' ' / ~ I . ~ ~ . ~'-A
.c 0~• J'~ 3. KACE IN ~AUtMOlE MAlTl/1Np, WMlRE ItONOU7iCE0 OEAD L USUAI lESIDENCE twAwc Oeccosrd G.c< I( ~~,~;i„rom .es.dewce botwe
.d~...s~;~„~
O A. SiAiE COUNiY
N V ~
~ N~v Ntl NAME OF' pf NOi IN HOSPI7Al OR INSDTU110i1, fiVE STREEi
O ~ V~ p ~ STIIUTIONR AOORESS Ot IOGAl10N1 c.un o; ~o~vN D. INSlDE QIY lIMRS?
r ~
o ~ , - - :
' ^ . ~ ~
• ~ , . / , ~~J~~ f ' r rFS No ~
~ ~ ~ ~ ~
' O~ C~' O I ~l.c l% fr E. SiREEi AND NUM6:R - i
C v O.` / i L , _
o~~v ai ' _ 7 . ~'-'c:
i. SES
j 1~ n R/.GE 7. tiuF~~ Q HEVER ldlARpE~ ~ d• DAIE OF NITH'-- • AG~
Oa eutt . If UnCet 1 T~, ~ li Uedt~ 7i Mrs.
O~ r.- . ' i i ! biriticoy~ Moo1Ls~ Drys ~ Nwn ~ nu~
o ~ E o ~ M ~ .v" v~nooweop avoacEO p ~ : > / ; ; ; ,
O G1 ~ 0•" IO~IUSUAI OCGU~ATIOHI~~e vw? 1D41:lHp OF tUSINESS OR IHD STtY 11. ~ItiNtLACE(S4.te e~ [oreige etunlyl 1T.CIi1:EN OF \YNAT COUNitT'
v C d~+N dw~ap es~t d rra+4is~ 6k, wsa 7 nliad) ^ `
.p ti~ C C O . ~
V p C N~ = , ' c - - l~/Y;
'U ~ O~ 0 ~3. FAT?IER'3 NAME 11. MOTiIER'S I.UUDFN NM1E
" _ a
oa;«
~ _ ~ ~ ~ ~
~ ~ ~ - .c c :o
U
<<" p 5. Was O~ceased E~n r U. S~ iy e~ces SOCIAL 7. INF02MAtiT AODtESi
! t f 0 C ~ O ~ (res,na cr raknowwJ tl! yes, qre r~w ot lales o( servicd SFCUtITY MO, ~ ;
~ ~ ' Y 'D V C . ~r ~ ~ _ ` - 3
f: :i~ ~w t ~ . 1C < <
f i,~ M"- v V C ~ 1e. ~ CAU E Of QEATH AN~OLY.~i( IHIExV/1j
s
" ~ ~ETMfEN 0.v5(T AHO OEAIH
p i c~-p O(SEASE OR COt1DITION OIRECIIT
~ q Q ~ 0 Q ~ IEADING T~ DE/~TH ~A~EDL~IECAUSf • . . ~•/i ,i i • ~.•j!, i i'
~ e (TFis docs not rr.aos tl~e mode o1 dpin9, ag„ pUE i0, O~
l15 A CONSEQUEl1CE OF: i
v i ~ O a, p hcod (oilwe, oslhenia, e!c. (I meaas 6i~ d~seos~, ~
~ n r a Q~ iajvry ot complicnlio~ wltich cautsd dcou.) ~ ~
~ ~ ~ p ~ ~ ANTECEDENT CAUSES 'r } ~ ' ~ . r.: . ~ . ~ "
_ ~ o E"'s p e . , . . _ .
C> o Q ~ DKEASES OR CONDlTION p on '
X ; ~ S„ r. 9iria9 ~~GUE iO, OR AS A COKSFQUEnCE GF; j
- o o~ C 0 use b Hr~ obore causo IN sfaf:ng 4ti~
C•- M UNDERLYING CONDIl10N IasL (~1
~ ° _
r; iri Nu •O
v r ~ ~
U'J j~~~ p OT}iERSIGNiFICANTCONDRIONS CONif.IBUTING
' ~ .C C` ~ TO 1NE DE:1Tri QUi NOi RELSiED i0 iHE TERMINAI
Q 0~ Q DISEASE O,t CONDtiION GIVf.N IN VART 1(;~1.
~:'i o v v 19A.pATE Of OPERATION 19~. CONG710tt FOR WH{CH 0?EtA710ti AUlOfill~ea o~ Fs 208. IF TFS. WE[: FItiDINGS CONSIDEtED
" ~ O ,t ~N ~ ~ " ' % ~ WAS fEtfOtMEO i IN CE1tTf17Na CAUSFS OF DEAiNT
; ~v U ~ • W . . . 1 ~ ; : ,
~ C~ _O N d a p V 21hACUDFIST \YAS UtiDEiLTINO 21RtlACE OF INJURYIay.in u obout 21C.WHELE OID P! In Bo1WC~~ CP.y, pirt caoct b:otta~;
s: w OR COHiPJ.Ui1NG[]CAUSf OF 6anq lamti bctory, skce~ oKce Md~. INJU~T OCCUL•
O ~ O~ u DfI.TM (noi:y me3co1 cacmi~a) ekJ
~ f~ Ci l
~ CL ;^1f O 21Q.i1b1E lMoo61 IDo71 pcad (Hor 16 (NJUtY OCCUR[EO 21F. MO1Y Dl~ IHJUYY OCGURT
~ N~ h~ ` W OF ~HJV~ /
.t ~ nv C ~(%~tpROJG1 ~ib A/ Hol W6ib
> C ~ 'p O W~elt ? -A1 We:k ? ~ ;
el
C k p a . 1 cerH(y that (1) (thls hosp(tol) ott~nded ths dtcsassd from 19
~ c« O p 19 to '
o~ v~ O t6at (1) (~e) (ast wrr tha dx~os~d alfw oe ` ' ;
U._ t A - 19 and thet tn(wY) (wx) opfnion denlh ocurned on tM doto .
~ ~~o ; 0 N cnd Iwur end {rom t s ra, (Ij (4~1e) (dl~ (dld not) vlw? she bodr akc: decth. .
~ ~ ~ No ~
aastict~~~v~c ~ ~
.v ~,,y 0'~ E ~ ~ I. DAT[ SlG:~ED
_r^~ = F ,r O _ . , / 1 A1Vqd',wa M~d. S?cg .7 i
~ V ~ a ' - I , ` - ~eto~rE Phy~. ? D~»cfer ? Pk~s. 0 % ` / 7 /
L•• L a b~ 23C.?II1StC~A 230.ADDlESS
~ O O KAME ~TI / ' ,
f:; ~ ~"r-~•tiit i~ 1 . . Y i ~ ~ - ,
f ^ ~ 0 2lA. iURIRI CA'P.1Ail0 O ~1 F1AEiEtYDi~. GREMATOtT ' / !0. IOCAT Ot1 t • _ : -
Q P 1JV.OYAL ISpcci(~I . . r ~ h. bv.q M covr.:~! liwfd
u O ii (Q a M1 / J 1 l' ~ j ~ / -.~l,
^ i V « -j ct~ ~G'i: i _ ?.CiE t.: ~ ~js/j~'~~~:.;~ 'J ~
' ?GA, pAi: ~EG'D CY HEAI E Of IEGtSTi ~ ~ ~ ~
• =S ~ ~ ~ SG fUNFQAL DILEC70R s
t r DDZSS
i ~ Sro 3 I ~,~xf~ t~ ~•t` ts.~;,i~ - n , , _ / ~~.1. - i...
k - ' ~ .t >f . ~ . „
VC 1N ?L\• •I~iti -
~ TNIS IS TO CERTIFY THAT THE A601'f IS A TRUE CGPY OF A CERTIFICATE OH Fllf
tN TIiE EAITIklORE CITY HE~ALTH DEPART4ENT. BrLTI'.4~JRE, MAK1lAl1D.
NfARNfHG: 00 NOT ACCEPT TNIS TP,AtiSCP.IPT UNLESS THE CFFICIAL DEPARTNEtITAI SEAL
IS AFFIXED HEREOk. PLEASE NOTE SEAL IS IN @LUE
IT IS ILIEGAI TO OllPLiCATE THIS COPY B~ PNOTOSTAT OR PNOTOGRAPH ,
~j~ S
n 3
~ ~ i~lc i'A~~~ U"w~~-~ .~a,~.0_,~w~ M.A. ~
~:~;:;~:--~r~T, ^~'AU OF YITAL RECO°DS C,[T~"~1ISSIGiF.N OF HEALTtt ."'':r T'rCiT;'~~=~•~'
~ - ,
. .