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HomeMy WebLinkAbout2174 Jr~ ~ ~ CERTIFICATE OF DEATH ~134 ~ ~ ~ocu .ue w..ue~ 1N!tiip~ Op~l~w~ d 1tib11c l~beM suw ~we .w..~n 0(C[ASfO-AI~,Nf hl3t +~eq! ~~f! IDAiE ~F pEATM ~ rOw~w, O~t, tt~~ ~ + ~?A1i :3 T=i~TtL:v%:L : ;'z?.e ~Phruzrv 1 19~2 R~CE ~MIfI. M~G~O, ~rI~K~M Mi'.?~~N. wGE-U.U ewe~ ~.t•~ •u.oei o~~ or aan~ ~~...~w, o~r. CO:A:1~ Gf OEwiN ~ ea. ~ snc•n, ~.MO j ~.i..~~ ws. +e... an .ows ..r.. ~ ~ , ' ~ :~ni~.e .s. '=1 s~ k :~~:a~• 12~ ! 91n ~r. :,i?~~tnr3 ~ c~ ~Y. V:lli~!=E. 7R TOWNSMIP OF OEATH wsre cm ~rns q~sf!TAl OR OiHER NST~iVi10N~-N ~r «w ~N e~n~e. ann i~~er .w ~wu ~ sr~tv.~ .~i w wo n ~~rcien ~~tv Yes sarden Cit~ Cs..Fana1;•.i~ uosvita~ STA~f Of {!~M e N ro~ u~ u.t r~~rt d11ZHJ Of MI1MT COlMiR1f MAtbEO. HEbER MAlMEO. SUR~NNG SPOUSE ~~r rnre, ar+f r~eeM +rrt ~ cawx. ~ wIDJwEO. D ~ ~wc~., ' ::ti...~ ~es•oewt~ ~ 1~P11tl1CZCV 1. ~1tGY1 Jt3f:@S N :.~t•2`l~~ Fel~ea _;arc^mare~^.Y~ ~,«.uo - , „ n,rn SOCtu SECURi1r MW~fR USUnt OfGL?i1Y,~: ,.u.e ...o a.ws oow owwa rosr a rw OF M!Sl~SS OR IHD11STt~r c<c•.~e~tD ~v vOUwG ~W. hl.. v~tn@o ~ .,y,.... ~~w 7~ ~ .~+cwce ~e.esq ~J i7~ _ 1}~ .c lea t:c~::lt'I' ~ ~~1U~1.^.3~3~. .c.. ss~~. ~SIDENCE-STAfE COUHTII ICIiY, VILUIGE OR TOVYN$HiP 'N~ t~n ir~ Sillfft wN0 NUM~ER L~~~ ' '~sntw~ ns w auu ^ ~w a._ ~a vn ~w. ;~a j-* , _ : ~ ^f,: n ~:3 ~ ~t;~i`[~OY'21 Z'TF'1Q11tS i ~u i?5 c.: S~ rri.r_cetc'_'! FA?MER-NAME y *pe~~ Wf MCiY{R-MAICEN NMIE ~+Kt r~pp~~ y~~~ a ~s Char?_ ~s ~ L"hir? :.Tei 1 I~'ar~;aret Flo~? pn 1~"-~~ ?~l?llt~G wODRESS ~smt~ oe ~.r e..a., an o~ tov.., s•.rt. tr~ n. ~ elexa `i'!l~r~~al? - ~ ,n :'.K'tz5 ~-ri-~cc :or "^a.r?~o~s: ~-l;±s, .'?.cn'. • -an ~'1 " - ~ARi 1. pE~TM WAS GUSEO i jE41ER O'+lY ONf Gt:'Sf ?fi [Wf ~OR fe:J(b~ ANO (e~j •r?: ae.+~i ~ .evlD~.sf! C~cS! .Ntir.[r Or.~• . ? v.•r } ~ ,P./YCd'~P.t~~J~i.t~~ ~.iZLs'-fl.Ql.s~i'~ 6IIf1~. • • t~.uw ~ coMw~~oas, ~r ~ • ~ .~~~cr o.re use m~ Iel ~ i ~ . ~r.~a•~t uuse ~a, j t ro, oe .s . co..u~x..c: x - ~++~.o *M[ uroee• ' ar~.~a c.usE .4fr ic) ?ART OTME! SICsH~i1C~Ni CONOITiONS- ca+anows caawun.w w w~w wt .wr ~eu+to ro e.vsE c+[.. w. r.n ~ a~ ~~u*O?Sr rE5 .t~e •.wo~wes .o«- ~ ~ ~iEt Oe W~ ' S~CItN tw pEtl~r~wN~~ :~~SE a oe~~w Ifs V°5 H~ ACCIDfHt. SUKIDE. Ff~AMClpf. ~ A , rQNM, OAt, t(4f 1 ?10()R KOW INIUtY OCCURtED ~~~a +ururt •~r :Nr~n ~w r.?:r :~se ~in rttr r~ . ~ s~tan ~ 7M I~k ;y~ INJURY AT wORK ~~!~Cf Of INJURY •r »o~...~. sre~~.. ~,+-ren. lpvT~y . sm~ a ~.r.o. .ro., an o~ ~o.n., si~n ~ i srwn ns w.eo~ ~ana ~:-e_. ex. , s.eeu.. !a ?.~r ±ay ' CFR71f1UTlOlv- +~wn. w~ ~u~ ; .w..a o.• ~w ~~nJ 1~St L~rr ~tr/wtf ~iM ON i.1O/C10 Wt v.tr *Mt DEAM OCCYtlfD .r n.e h.;~. a., n.~ ~ ~NrSK1wN_ ~ rOwr1/ 1p . + Ml e~?~ ~ WG1 asi[i 03ay. I.MDV1~ Oa'f. w•:O. K. wt f!S' ~ ~ ~R[Mp~p Mt 1 tl~ oecF.uo ~~o. ~ ~ I. ' I~I ~ Z' Ittc ~ 7 Z j ttl~~,~ T ~ o. r. c«^~uo~[. e~:e t~~ ~t ~c :+t e..-i~ ~ si.:ea. CERT~ICA~Ipr1-w,fWGl Et,w1~~ER OR COtO?~e~R: o.. •~r ~.s~s -«e e~rE CKtOEw• w.s r~p.Kw,,~EO ce.o - eauw~uo.s a ew wor u.o~o~ rwe ~...ESnc..ro.. a?..w... s rwn: a.r .eu ..~,N ee..n occv~+~o o.. w.E o.n ..ro a.e ro .~e c.uu s~ ,r.~:o ~ ~ _ i M. 2:1 M f CERTIFtER-N~11NE ~nM O~ r~w•~ i t S~GNATUR j , atwE~,w ~~T.~ OwTE SIG?+_A ~+.e.r., c... .e.,:~ ~ 11~. • t•. • ~71~''~17 'tN - ~_~~e~~~l~l/ (Jk~ C^• 1' ~t ~ ! MwMlNG wCflRESS-Cfffrf~Elr s~u~r w~.~ o. ro un w~.~ s•a - _ - _ ~ _ ~n ~ ,7 * , ` a:a~u. c.~cMwnonr. ~MOV•: ' - ~ - - - ' • = . • : . ~ ~ iCEMEiEif O! CREMA70RY-?~.u+F - iOUt!fiN c~rr, v::~.weE. iw~. oe ca;~mr s..•. ! ~ ~ sntm ~ 3 , ~a ~.T'1.?Z ~c:.3A11 ~.C _^!02`i3~__~~11k. ~i~Sic.~ST1C1 ~ Cl1i r3''i ~ i DA1E r..o.rtti, y~, •t+a~ ~UNERAt HOMf-nu~+E eKp 4xRE~5 • st~[[t O~ ~.~.o. ~+o., cn~ ce to`.M, s:~rt, z~r ~ . ~ K .Jr. '?1 ~ ,~.y~~-• ~ ~ ^ ^1n - ' ,•~,~5, . ~ ~ ~5 .'4 ' • _ s - ;:!a.,;" ?t'Q_"'_- 7 : ~_iC~ _ v?~:•:13.'~..:i _:c~t'^~r•y. ~.tt. 1i~1'~!, ~ fUNERAI b~iERCR-SIGNAW~E j p.E~.:ptRAR-Se~'r~.,1~J?E ~ owtE +KC.. ~ 8 , r, ~ . , ta :,>;r? icwx¦., . J ! . ; i 3•~~~~ :s~v,).c.tr / •-~{i'./l~ SA~~'"r! 'li ~--I ~ - ~ ti 7N ~ . <~~~~~~'~1 I`.~: ~ ~ ~ ~ - ~ ~ - ~ ~ - ~ ~ - ~ ~ ~ ~ ~ ~ ~ ~ ~ _ ~ ~ i i i . - ~ ~ : i - ! F ~ I~e~nS~ certify that ~h~s is a true eop~y~ c5~f :.a ~ ` record on Pile in the o~'f icP o~ the; Cit :~C ~~k, ~ . , , ~ ,~~arden City, Nichi~an, as attested *~=~~4~'}~~-:~~ea1 ; of the City of ;ardtr: C~ty, e..^i.~} ossed ~erzon,~~;,j t - ; . . ~ _ ~ ~ ° - ~ . - ` F EB 1 ~ 1972 - :~i ~ e , a ~ - ~ i ~ ~ ~1 m . F . ~pg97'-s ? ex'k , ~ ~ i ~ ~ , . " x. ~ ' ' S~~ ,=z . - _ ~ - • - F~.~- ~ ~