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HomeMy WebLinkAbout0165 ~ 232940 , - s~,rc nu ~c^rr..~ i s~•r~ro. REG~SiRAT10N 69 ~ 9TATE OF ILLINOIS ~uw~[• _ OISTRICT NO. • ~ REG~S~ERED 4~ MEDICAL CERTIFICATE OF DEATH NUMBER o• ~r .s OECEASE~-NAME ~`~s* Mioo~t ~~s~ SEX DA1E UF pfA1N ~"^vn~. o~~,~~.~~ GERw~NENi1NK s.. ALICTs I TRAVI3 Female September 15, 1970 KM. d n,,,~b,,. - ~,,;p~ b, RACE rwnc.~tow.~MC~~r ~ro~ar. AGE-~~sr NDER 1 YEAR• N ER 1 DAY OATE OF BIRTN IrONiN.04~.+(~N ~PtACE OF DEAIN ;NirPVCr~pNS cre- Is~tar~t ~~~tMo~~ (rR~.l. wos. . o~rs • ~o~~s . rir. Whits s~. 71 'csb. • ;s~. ~ a. Aug. 11, 1899 ~o. Morgan CA1, fptN. ff?. Of ~WO O~STNC1 l~UM~(~ ~ ~NS~O[ Clf~ ~ MOSIIS<L OA OtMf~ ~rsn+utwr-NAMf I~~ ~t ~N [AM[~. 6~Y~ t11~E[~ ~MO MYM~(~ , ~~r[aJrol ~ ,b. Jaaksonville Yee ~,d. Passavant Memori4l Hoapital BIR1NPlACE Is1~tc o~ ro~cww C~T~ZEN Of WHAT COUNTRY MARRIED, NEVER MARRIEO, NAME QF SUNmNG SPdUSE (M~1DlM M~Mt. 1/ w1IU cour~•.1 WIDOVy~~QNORCEQ ts.cuM ~ - e. Wiaaonsin 9_ U. S. A. ,o. w ciowect SOC~AI SECURtTY NUM6ER USUAI OCCUPATION ~ K~NU OF OUS~?atSS O~ ~?aDUSie~ ; U.S. WAR VETERAN , WAR OR DAiES OF SERVICE ,1vE3/~O) ~ i2_ 329-05-4ie4 ~~~e . Nurae ~~~b. T. B. Sau. N• RESIOENCE s*~*~ ;~~T• ~ dT~. iOMIN. TM~. OA fp~0 O~Si1~CT MO. • 1MS~DE C~T+ ~ sT~C[1 ~MO MV«RA : ~ - Illinoia ;,,b_ Morg~n :,.~Jack~onville c, dYea ~„e.989 N. Church 3t. ~ E fATHER-NAME ~'~s~ r~DCIE ~~s* MOTHER- EN NAME ^'s• r~onic ~•sr ,S_ Ja In eraoll Hele~ Unl~nown INFORM NT'S SIGN ra~ .I'~ RELATIONSHIP ~ MAIIING AODRESS ISiA([T ~MD MO O~ A. • o., c~++ io•r, s~~rc. r~•~ ~~r • N; ~~b. Da ht ,r~. Jones Pl Jackaonvi lle Ill - •eI~U~~r~TE IMTE~I~t 18. DEATH WAS CAUSEO 6Y: (c..~c~ o«ir ONE c.usc rc+ uwt r ecr.cen onsE~ •~o our» ~ PART I. ~¦MEn~~rc e.usc La 8 I'A ~ • YCiE C011N mi,nutes 3 - - - ~o~ RoCER P0~~1tAi ' ` `~Hy~rtension RECORp vEp:p~Ep~ severa yr GONDITIONS. ~f 4MY~ ? w~~c~ 4~c nsc To Ib1 ~ ''j ~ , IMM~OI~iE C~USE (~1 W~ • COMS{OYENC[ W: S~ 'T{~ ~ ST~T~40 ~ME YMDtA~ ` l~IMO C~Y![ Wi. _ . ICI ~ ~ PART 11. OTHER SIGNIRCANT CONDITIONS, ~~+*~~TM~ T~ w~ "o* '~`n° ~o ~wuu w[" w r~ur i~.~ AUiOPSY YES. ...e...+ c..- ~ - hEl/MO) ~ a~ sr.ir, D~tf~M~~~N l~Il~t I 190. N~ ' 19b. ! DATE OF OPERATION. IF ANY , MAJOR RNDINGS OF OPERATION ' ' - ~ ~ - - ~O ~ ~ ' _ ; 1 AITENDEO THE ~~*M, o~~, ru~l I»o~tw, o~~, r[~~I ~ ~wo ~ast s~w ~ir/ IYnNTw, D~Y, ~[~~1 , NOUR Of DEATN DECEASED FRO : TQ , Mc~ •~nc uw~ j 210 ~ ~ 21b. 0'21c. ' v'21d. ~ M- l CBRTIF TNAT TO THl's BFST OP MY KNOWL6DG6 TNIS DEATNOGCURRED OT6 IF AN :N1URY WAS lNVOIVE~ ~N TNIS OEA~N, ON TIlB DATE. AT TH6 ND PLACS. AND FROM TNFi CAUSB(S) STATF.D THE CORONEA MUST 6E N01~FIED. ~ • SIGNATU ~ • ,DA1E S p ew+~.n~r.~c~~? ,ItLIN01S IICtNSE NUMBER _ no. ~ • : nb. ~ / ~ ; nc~ A'~ TL ~ - MAIIING A~ ~ CERi1FlER }~~crr o r~¦sc• r n. cm e~ roT.~ s• * _ ?3. ~ ~ BURIAL, tEMAt10N, ~ CEMEIERY OR CREMAIORV-N tE ~ IOCAl10N ut+ o~ roww snrc ~ Q(~eiE~t: rOMiw, D~~, ~t~~1 REMOVAI Is~[c~n0 ' 7 ~ ~b Buriwl ~z.b. Par1c~ieW Cemeter~~k. Peori4, Illinoie ;z.d.~r~. 18,1970 = ~ FUNERAL HOME NAME sr~[n ~+o ~u~~c~ o~ r. o. an oR ro~w sr•r[ :v zs~. GILLHAM. - BUCHANAN 326 West StQte Stre t JQCkaonville, Ill. ~ FUNERAL OIRECTOR'S SIZ'iNATURE ,~UNflM p~~EC~Ot 5~U~NO~S I~CENSF NUMbE~ ~ ~sb. ? ' ~ ~ ~x_ F- 266 LOCAL REGIS ' S1 ~UATE RECC. BY IOCAt REGISTRAR1~o~rN,ow.~t~~~ ~ ' z~_? 4~ ~26b September 17, 1970 ~ Y! 20p--119~Mt ~ S OE~A! NT OF ~UlIK NEA(TM~WtfAU Oi YITAI tKO~DS ~~ASEO ON 1966 U S S*ANOAfD Cf~i1f1~ATE1 v-. ~ 1 . ~ It y CF. RT/FY 7'HAT tke ~$r~goiria ls 0-true and eonect copy oj tl~t dea~h ~ecord jor the deeedent named ot itern l. ond that this ~ ~~tab1isbtd-cnd ('i~ irr7ry oj~ce in accordance with the provisions oJ ehe /l/inois Vitd Statitties Aet ° ~ ~a~y~_J~i _ -i , • ~ ~~A~IT'~ ' ' September oZ~Z , 1970 s~c,ven ~~i-C~(iud ~ ; ~us. a. Illinois. OFF/CIAI. T/TLE ~cal Re¢i~trar. Jackaonvill,~, = , ~ . ~ -~~I rtco?do/ thlt'deoib ispsAl~m~eAely filed 4a~A [he lLLI~YOIS DF.PARTMENT OF PUBlJC HEALTH uc Sp?in6/'itld Coeintr elerks andlnml ~,~•r autAodstd to rKak~ es/tijteatio~s jroiw eopies oJ the orisina! ?tcord The Illinois statrtes providt thot tbe eertiJ'ieaeion oJ o deotA r~mrd ~ ••;~Tnrtment oj P~tblio ~!/s{t~dt tlre Wed ?e~istno? or Ne eorntr cler~c shd! be conaidered ai p?i+wu joeie evide~ee Rf CA• t s e~aeiw '~6~165 UK ; ~ g (,M ~ ~ a ~ Rl REAt' nF 5T.ITISTlCS - ILLlNO/S DEPARTXENT OF PUBLIC HEALTH - SPAINGF/ELD 627~6~ ~ ~ . _ ' ; ~ ~ _ ~