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HomeMy WebLinkAbout1326 . _ - .__:___••tRTIfIt~C~Y OF A DE/1TM Rt~cO_. . - • ~~tt IN wr1M lrrfw~,rER OR tEG~1lE 1R~Nl~NG . COUN?7! RECORD STATE OF ItUN01S s~~~E ~~~E Nuu1f~ otceo[MTS MEDICAL CERTIFICATE OF DEATH ~~+~St~A~~OM eE ~ s•F~F~ ~~~tH wp. ois'~~Cr NO NuMsE~ ~'l~ ~ ~ ~l/?CE O~ ~EAtN ? USU~t RELOFNCf ~w?..~ r• o- . r. • ~lUNO1S ? COUwr~ ~L!'~ ' yiw~E ? COU~ir „ f~ ~ „ . f'~J ~ t~ INSIDE cwporo?~ /:iw:M «d C~?r. v~eoye. or i~cwao.o•ed 1o.w c. WS~OE capaw~ i.+. wd G: Y;t • j ~ hr. le~. O• !w~wOwo~ed , ~s Arr~rR1 ~ Hloa~n#.~„tim, IIlino~s ~ d. Q OUTS~~E capwor~ /:w;b o~d ;w ~ N N w d. OUT + ~N ~c v~a S OE cavww~ wd ~w itko'.• e~ ~tS'7Fr'F TornaA: o• te i O ~oiw~ 1p.nµ~P ro~~•...............-- ~ Raod D:~~..c~ No . . . . . . . . . . . . . . . . . . . . Z ~ Rood 0»~.:a~ No.. . . . . . . . . . ~0~: ~~@ v $e NAME OF HOS~ITAI OR INSTITUTIQN p. ,MN' w RfSIpENCE ADORESS ~1~•e~~ 6 No w t f 0 e'd ?q~ ~a•~~ ~~t'" rA~!:S.~tr~ .1 ~ ~~O'~I~d1.'a _ Z"' 11 r? 1~wwb~ w~~u:~.~.w. q~.~ S••~N ~ Ne. a R f 0. ~~d /w~ WI~c• ~ r ~ Q. O~d 4KM/M~ 11{.~ ON A ~A~Y~ "ES ~ v(' ~ ~ 7. NA6AE Of i ~ b. (V~ ~ ILA 1 1. DATE OF I4 NTN, rpA~ +£w: ~ECEI~SEO C~1 OE/?TN .~k,~1' VIELt? • J~Q ~1/~ I:'~ ~ - ; s SEx s t~CE T M~Re~EO NEvER nawRRiEO ~~1E OF ~iRTH wGE ~.~..e.~ ~ l~ ' I I W O IVORCEO (~o~c:l S ~ , ?~.~w~r) .w.. . ~ 1'~1~Ib ~li~ ` F ~ i~0~. USW~I OCCUMTION lQ~.KINOOFSUStNESSOR INOUS~RY ~ S~RTH?tACE (C:hr owd der~ w lar~;~n ro„n?ry) t~ G,r:=~. o..•.~• V ` ~ •a„r.~~ U ~ FATt~ER'S iUll ~s. tr TMER'S Wtl H ` N~??dE i r . t`I/1iDEN NAhAE ~ ~ ~S. ?'roi wceoa~d ~.w :w V. S. Aiw~d Fo.cn? ib. SOCIAI SKURITY t7. iNFpRMANT ~ I?N. ro. r~?L~.y ~6%•~.r r N?e~ r~r-.aN NUMlER . S16NA~URE ~ 2 ~ ~R~Y~~ ~ti UUSE .u OF OEATH ~ - I?ODRESS c REU?tONS~'tp 'p UECE~SEO a~'c MEO~CAI G1USE OF pEATH - I ` ~A~T 1. OfA/M WAS CAUSlO Ir. IlMr w~ W ~e~.M N• ~ Ir (A!.1~) W(G~.1 • W IYMEIIATE C/?YSE IA~ - ~ IN~HyAt ~fiWEFh ~ r.rv~, ~~a. ONSET wvD Df~T•~ y~ . V{1r~~ ? 2 Q GO+di/ieq. i~ OwY. . a~ J M A~II~II.IE~IATE l~)........ ttiY~l!~:~t~.~tiL _ O, t~~ Z~'.Ti~ ~ cwusE ,~+:y yrn~ 'j ur+oft~ri~w » ~c~ r uw~ 4~f. w n. H ~ i ~ u i . ' N G~YEN IM ?Ati IIA)- • AUfO?51'~ ~ S N 19~. ~Ai~ W~~[Y~IN. n u~1 (id, r~~ •••~~q~ w w~~~tw. ~ ~ Q rf5 r NC 3 ; , ti ~ NOTE: H~n iej~ry .r~~ ~~w~hrd i~ Ma i~~1h. t4 Cw~r wwt b Mfi1'~. ; ~t I?I. «Aa~ cr?'h'??'4j~ Mr~~~ M~~w~/ ho. ! r--- > 1 -~+1~ 19_ . N_ . 11 .1A~f l l~tl ~wr MN d~ttot~d cl,,,~ ° ~ . t~ Md deoM octw.~d N 1: M.. IA. M.~ cNM! r/ ~w ?w rM~ t~M~1 Mw~. ~ ~ I / ~ ~ g I S~qnNw~~.S/...i?!. w~.~"iit't....... .._....-••-•-••-M-D. L~c. No• ..........~~t~ . a~•~r'' ~I • : [ N 1. ~~I~ ~ ~dh{~........,~~..~ Y~Zf~~ ' Q ' .M10N~... w i~_ ~ ~ `22. D~SiOSIT~ON: S(}RIAL-REMOVA~.CREMAT~ON O~N.... , ~ . ~UNER/?l DIRECTpR - i - - ~1 _ . . ' t CEMETERY ....3'.~ StGNATURE ~1~ tr~ ~i ~t . . . . . - - • - • . . . . . . . . . AOURESS . ~ ~~~.1 v~ ! ;•~•e ~ • : - _ ` lOC/1TION . . . . W.OQd''1~iO11.~_ ~i . . - - - ~ - - ~ . . . . . . • - - ~4~' ~y • - ~ *Mf ,tUiMCR~~Y - - ~ • - - - . . . :.~~~M~C.~~> ~F i ~ N.,~.,~. 2.. ~ r - = i~E ^F /LUNOI$ ~ 24. R~ce.+~d /w (j:q+~d) ~ JumYe 25, 1965 Glittc~re Y. ~aneo~a ~ :v-s~~i r~ xs 5.~. c ~ - - ~ 1!l~;REB}' CERT/FY THAT tAt Jo+xyoixp i~ o trus a~d eorrset topy oj L;. ~ d~atA ~cterd %or tA~ dtceds~t •c-• ~ ~ n. d N?nt chit +s~ord ws~ qtaoluhsd n+d ~S:sd i+e n?y ojirr ia ~••-~.donre wil' ths prorisiow~ o! th~ !!(isioia sfat~.• , ~ r~ ~e~trrt~ion oj MrtJ~i, ~ti/l6irfAt ew.i d.n/Ai. , ~ UATE _ ~ - - - 1~•;.`' ~~.(;~"L:~ _ ~ . ~K! L ~ ~ ~ AT - :tiCT8ta1 - - • •'F-'~~:1~' ..Ti.E L` ' _ ~ - ~ r ~ r•e c-.c'~~i reror.i of tAir d~stA is :~e:mscen'~. . rS.L-VU25 n•...iFi~~~t " ~ , _ _ , . . . ' `v ~ .Y+. r~ce a-~. wuL^n.~sed te mak. ctrtdic~tinn• !r. ^ a~;Y• tAt ~•n?~.' :~c~a'::nr: Y„Al~c He~ltA or !he lue~l nt~~•••• . • ~ - ' ' ' C ~ ~ vStR-:~~A : C'~R'vEtri OG 1ULUG f+F~1t--+ . . . • • • r - . . . ~a ~ . .r . ~ ~ ~ ~ n ? ~ ~ ;i d ~ " ~ ~ N ~rA- ~1~ - = v~OC~ _ • "1 r.... _ = ° R 200 ~ 33'5 x ~ mo = so~~ ract - _ - 7 - ~ 1~ ~ SA ~ py-~7~0 ~~T ~ = CNr~ ~ ~ ! O '-s N ~ - . ; - _ , ~ r Q'^" : : -