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HomeMy WebLinkAbout0187 t ~ / . OH10 DEPARTMENT OF HEALTH _ ReR- D~x. No. DIVISION OF VITAL STATISTlGS ~'~e File No. Primary RcR• D:~. ~u.~ CERTIFICATE OF DEATH R`R~~ni s l~o / _ DEGEASE~-NAME lis~t .11iddlt [~at SEX OATE OF DEATH !~iow~b. U~f, 1':.rr1 lrli:t.a~L:~S .?`~.~Y^n ~ aa~.~~ 3 Ti T:i~: ) -_I; j RACE R'b.~e, ' AGE- L,.u uNoee ~ re~?¦ uNCFa i ~~r oeRe O~ t!R~a l.~4.rrb. V.,t. COUNTY OF DEA7H i~wli.ur, da (S "~t-: Irrrlb.Jr~ l~errtl ,yss. D~tt Horn .Niw. ~'trr) , ' i. ~ ~.~isZ. 4.y-a v-~1~':So. J~: Sb. Sc. 6..:~. ~-'r ~y~'-~ 7o.C.i~1i'.i~~~_i' CT~, V~i ;'O Qf~~ INSIDE CtTY LIMITS MON'~iAl O! OTMER INSI~TUT~ON-NAMf f/! Kot it titbtr, sirt shttt rxd rvir~tr) a - ~ ' y ' j_: ti~', - • _ ~SO i!~ )as wol O - t~ s-,~s~;''..~Y ~c. ~ J 7d. Di:l[?::' ~..~~xi1Llllltf CC'T~2ri' l. -~QS1^•1L<~ _ STATE ~i i~L~ J a~jf~ Ij,f,A.. ~~i'° C11/2EN OF WH~T COUNIRY MARRIED. NEVEft µaReiEC. SUtvIV~NG SIOUSE I/J uijq a+r~ w~id~w wrN E carws 1's` • f: ` WIOOWED. OIVO[CEn ~ri lI C L'i lt' u ~t?:l; ^ ~ e_T_:~~ ~...t~~~~;'~''~.;.f:'f~;' J. . l0. 9/ ii. l~tc\~_$ , . . _ • - ~ F: ~ ~tA , SfrAR1~~RJU~1tft~~; _ WAI OECEASEO EvER W L~. S. ARMEO FORCfS~ v~~ Y~ fYu. ro~or s~wcr+~r1 /IJ Ju, trrr u•~r or d~tr o{ tersitel ' ~ o~ !?o. I .t ~ ".~L~~LUZ "~is-. 12b. 'C' ~ ; i 4 _;1, l.57A 'OS~ X IC~1~ .l:i~~i Ii .~s(. u~?4 if~st 1u~irj ~rost ~J t.~,~ ~ K~ND OF SUSINE55 Ot It:pt15TR1f ti L 4lA?M( ~~r trut i( rNiieJ1.~ ~i~~ ~~a_ ti' v ~ - :~~tire~] i v f , ~ , - ~ tE~ D?:I~E~j/A1[ r~ CITY, VItIAGE OR IOCATIOV INSIDE L'li1 11MITS STREET AND NUM6Ei ~ ~ L+ ~ 'f r-1 .~4~ - ~~j~ tSr~•u! :":J 1f 5GJ ~ ~ lae. ~::Zn ' 7 ~liuy~~fl~:~i tac. - ~:?~:ll~? ~~Z .'I1~$ IId. Y~- it~. ~~3 ~~~Y:~ .'~~;.fi 1 ^ ~"~i c ' FaTN.R--rvflMf C»rf ,f:i,{Jit . Lr,t ' MOTNER-w.~uDfN r.~r.ec lin~ t~adlE L1rt , ~ ~i ~ i u I; ~t; t _ .r',~1+°_ 76. r. :l•':il . I iNPORMANT-NAME NAIUNG ADDRESS rsr.«r o. K.~.D..o., c;rj o, urr~ae, ,r.ue.:.P~ i: _ ' ~~e. c'•.I-.I: ~ "r L' »b. r L 5'1 F'~ G'2 ~~4t-=- ~ .i ~%.'rt?l;? ts s U _ _~wir DEATH WAS CAUSED BY: iFNifR O?vlY ONE UOSE IEt UNE f02 tol, ib), AND IdJ• ~PiR07c~vAiE ttrTEi~at '8 6ETWEEN N Ei wND Oi~.?t1 o; ~cute anterior Wa~Z cardial infarction da s t i l=. INIMEDIAiE tAUSE I~~~ i7 DUE TO, OR AS A CONSEOUEt~CE Of: ~ --+c.2 corJ;t:o~r. if.•¦1. M?~;; - 1 J~ riicb trrt re ~ ~el COZ'Oriti arter heart 3isease ears ~ ~ _ ~i7NfJl.Ilf CJYfC I,i~, I ~ DUE TO. Ot AS A CONSEQUENCE Of: l ~ ttstirs ~bt rwder- ! ~ i !)iu ~arrt l.rs! ~ i~l ~ ?AtT Il. OfXER SIGNIFICANT CONOITIONS.I.owitio~t rowrdrrias to drslb br! rot rtl.ud Io r.trit =irt~ is prrt /(~I AUiO?S~ iF YES rne pwd~nsc toyiiJ. ~ O'tt O? wu i/r ddrrwi~riws trmr oJ ~i~~tL al infarctions • disbetes mellitus 19e. 19b. ; I ACCIDEHT, SUItIDE, MOM~CiDE ~ OAf E OF INIURr HOUt HOW INltit~ OCCURRED /Fa?(rr waarrr ~J ir~u~ i~'rrf I or ~art /1, ilfA 181 ~ i~-~ OR UNOEiEWiNEO (SPt:if~/ I.How~G, Vrt, l"t.r?I j..: i ( 20v. IOb. 70c. M 20d. ; 1 i. IM1Ulf AT WOtI( ?UCE Of ~N1U[? U bnirq l+r.r. rn~~r. l+~rorj, IOCAT~ON ISu[d 1(.l'A. ro.. cu~ or ~i!l+~e, ~trts.. ii11 ( ~ L ~Sp~t+ll J~s or ~ol ~O~e blJp., a~. ~S1~uh1 , ~ ~ 2C~e. ?Oi j ! 1~ CERTIF:UT~Ot~- .~!or~4 Ul~ 1'r•~ .ti~xrL D~T 1"e.,, nNO ta;T SJ~w N~M/n~e ! DiD/OtD e.01 DE~iH OCNR~ED .!t tbr plirr, a+ ~ ! ' hfY51Ci~N ~ A?IVE ON ~ VtEW TNE E0011 (HOI.i) fbt dute. .~wl. t4 ~ ± 1 ATiENDEC tME 70 r~ .11e~1h D.:~ )'r.n ~f~ER CEATM. fbe brit o/ ~+1 ' ( r • 1~ r~~ ~ 1 /crl~~• ~I C5/~1 I Did no~ ~:Z~f ~~~-~i.~st. d~:r ' 21e. DECEASEO FROM 1tb. ~ 2~c• 21d. • 21~. M, tbt ~ax~t/~) ilrud. , { ~ n ~ ~ Cf?'If~CAT~Ot~-COQONER: Ou rb~ b.nis eJ ~Gr rs.+.iK..:in» H~irr o/ J~~~b T6~ dtuJert u~~ OruworruJ da+J , J ~.J Ibt 6odT .+td or !1~t 1171'[iRjdLDN. ia a~~ o0i.:;o~. de.,t4 .~l~wtb Ur~ }'so IFop ~a~d»rd or ~nt Jris rm1 drr ro tLt r.wsrlr! itatrJ. ~ w f---! U O 170. Y. 2?b.. y'- j CElTIfIE~-NAME fT~pt Or p~iAf1 ~ S~GNATURE ~ D~sr.e e+ ::tlr DA78 S~C~?+fD ~ ~ ~ ~~3.. ~'r+ _h H. p~~tt•.M.D. ,~;~e ~~F~~'=-- M.D. ~ 1= ~l ~ MA~UNG ADORESS--CE+tu~ER ~FP1 OR t.f.D. NO. UlT QR riItAGE SiA/E # 21? Zai. 4~1 Z-1.RidQeWOOd ~Jr. PAR:•IA Ohio 21k129 ' WtiAl. CREwtwflCrn CA(E c~ N~uf O•` CF:qciESr. QR 4D~ {A+dTO~i?# ~7 • ~ IOUi~,.N ~~.iq. rrllo6~, or cor.r~~1 ISt.ue1 i ~1 - t J=.U .~J ~ J.la.v : 1, l._:.IJI lc.l L~~ l l~ ~ t ~~i 19'~' cc~Te;-~ „ :.a. .:~rt? '?14~~Leci ~i~io ' NAME OF EMSALA1Et (LIC. NO.) iUttERAI [ll R'S SIGNAlUiE ` - . C , ~ tuc. ?+o.? ~ ~s. ~loi•i~-r~ J. Gol,~bs~i 5~'v7 :1 z.. : 3»~ fUnEtAI fIRM ANO ADUlESS (STtEET r:0.) !C~ ~Y ; (STAiE) (il?) .o Lub; ~ v. C F~•.~r: 1. Hor:sg 5`~'~ ~ i?ir1. ~?~o~~u ~Zltna, Ohio ~~+1''~~ ' OATE REC'O •y REGyST~a 5 S~GNAiI~E / 'ti OATE ?EtM~i ISSUfO SIGt~ATJRE Of I~S~1 ~p~r~ RiAti OIST. NO• 7 , t, f ~ ~ , ~ BGGK ~~V J P!, 1 ~7 _ • • - _ ~r~ ` ~ ti. - ~ .w ~ ~ ~ ~ t. ~ x.1~.kr.. . ~ r