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HomeMy WebLinkAbout0185 ! LcR1~ re• s2.oo ~ CONI~fEC'I'ICUT STATE DEPARTME3~T OF HEALTH / Puirlic Health Statiatics Scction-Hartford, Conn~eticut U.S.A. 23~9~'7 . ~ Certified Copy of Death Record ~ - oECf~a-wwe s~~.s. ..~oo.c ~.s• ~ sex - • ~'~ZZL7~a '~C~f`f`t!'_^ ' a ~f~!p~ • n.tt tw[ wtwtw DATE Of BWTM WarM 0~~. rW11 MCE- wwtf. ~FOw. ~r[~uw AGE- usr woE~ ~ vu~ u+otw ~ wv OA~E OF OEATH tio~M D~~. vfM wa~r., trC R?Eanl Mwt¦o+r Ir[.uis~ ~ A Mouwt~ru~ ~ ~,R~ ,2U ~q •t~ k ~ . ~:-~r.. 2:+,1972 CONMTY Of OEIITM TOWN OF DEATH ,?105~TAL OR OTMER WSM1JT10N- w~[ M woT w e~rKR avc sr~cn ua r+w[A ~iew fi~ven ~ Darb ~ n- ~riff; r. :io~pit~l CITr i STATE OF BINTN IC~Y. I~of U.S.1 dTIZEN OF (~1'/ ~ YAiiR~EO. NEVEA YARRIEO. WIOOWE0. U15T SVOUSE M~iN. Ww ~MdM~ wMy1 ~ . DriORCEO, IEGALIY SEPARATED . fiunRar . ~~`iarried ~ohn V. SOGK SEplRI7Y NWBER llSUAL OCGUPATION IWV[ R+~O 0? rowc OOwE Ouwwi ro6i O~ KIND Of BUSNESS OR INDUSTRY 1~pR1M0 4i(, EVEM 11 IIE*~11Ep ~ „~63-30-' 3~' ,~.::ousewife .r Home itE51DENCE-STATE COUNflf TOWN STREET AND NWBER ,~.:;onnec~icut .~..~'~ir£ield ~kSheltori ~_~We~ley Heights w~s oECenseo w verEn~u+z ~ rES. e~ve w~w uw~ oa s~av . ycan res o~ ra ~ No _ fATNEN-NAYE sepT r001E u~fT MOTNEH-MAIDEN HIWE s~~ rpO~E Wt K~rol Baran a l.. ;rarv Hoffer uVFWlY/wt-wWE wulvxi MDRESS R*~m o~ wsa uo. ar o~ ror.. s+~*c nn .~.Dr. 'John M. Eoffer 1 Cotta e ~t. Rnsonis ~onn~cticut ~ v~wT o~?rn w~s Cwuseo er: t~rir¢w auv a+~ c~?usE vEn u?~ Fa+ W. rol. k) ;,~,`M~„ i i r urEOUTC uusE - ~ 3 k ~ y ~ W 'ti`~ ca.atwws. v.r.• wwa ro. w as . ca.scart~.c ~ t . wvE wsE To ~urca•rc wcst w sr~nw twc p~ w~oaa.uw uuw us~ eu~ *0. 0~ : ou ra a - f K, e . ~ ~ VART 11. OTlIER SK'aN1FICA~IT COqWT10NS: COMa o~iw~unw io outw wo* ~tu~r[o o uus~ avcw ru~r ~ w ~urOVSV ~!c YES wE~c n+w~ws wrs~oc~o ~TE pMlO~I 111 O(7-~pheYtrlq UtVf[ Oi p~~TM a rM `i fN U ' ACCtDENT. SU1(~DE. MOM~GOE. OATE OF rWUi111 awwn~. wr. ~'tno NOIMi ~ 110W IN~NJRY OCCURREO fEhTE111i1~T111~ O~ IMJYRt ~ uiJURV AT V1~ORK x a Oa tX+DETEiWwEO Wccvn /~IIT 1 M/11Rf N. I7fY NI ~s.Ean res o~ rw - 70~. ( lOG Y iN. 7N s p1.ACE OF tN,lIIRY MOYE. fa1r. iTKET. LOGATION ~sr~[R o~ wso wo. an ow roww. sr~*c~ SURGERY REIEYANT TO CANDITWN REip1TEO IN ITEM 1{ ~ IACT011r. O/lICE KOO. RC. IfRtYVI j 1 IMw M Mr~+rN f0'r M~M~M/ e ~ ~ ~ I 7P A f1 CERTIi1CAT10N-iMYS~GW'1: YO~RN W~ ~We ~ rOwrM W~ nEP~ uq uSi s~w~rWh[11 wuvE Ow DEATH OCCUNR/E~O O~+ nrt W~[. ~wD. f0 nE . ~ ~T7E~OED TnE ~ RM Y i0 Trt CJ4~fEW fTaiEf. i. ~ a2~t 7~2 t~ ~~7`~-~--~•~~t-~--~-~ ~ ~o«. ~ Zta p[C[ASEO f110a~ ~ !~R i~t ` CERTIFICATION-MEDICAt EIIAYMIEA: w rr on~row. Or TwE WtE ~wD w01M1 Os OGrn ~ nrt o[cEaEwt w~S rwoMaMCED OE~O prt t0 1wE C~YSERI f/~t[D. O4iw 11ElY?iE0 OM OI~ NOUT ( YOytn Mv MQpI ~ r ~ rn. Y. CERT~F~ER~NAYE rtrr[ a~ wwr~ S~GNATU E oc [ ow T~r r , ~ .~_a~ ~ ~a~i~ ' , • . 4AILIWG ADpAE$S-CEHTIFIEp stnEFi Or. ~f o~O. C a1 Tpw sr~tE r? : DATE D trOMn~. Wr. vtu4 ~ . ~ _ ~ O ; ~ ~ , . "y~ ~ ~ ~ 7M ~ gUR1AL, CiiEMAT1pN, RENOVAI ~ CEMETERY~ R CREMUT - ~ : IOCAT un o~ rOw s*wrc . ycas.~ ~remat~0l~ ; ~ Lverc~re~.~ ~ ~ ~CW Eaven ~ DATE nanN. w.. •wn , FtMERAI MOYE-N~WE Mq ADORE59 arircr w ~so wo. an o~ roww. sT~rc. rn Conn • Jan. 27,197_2 Jenkin9 Funeral Home Inc .12 FrGnklin St. l~nsonia iINiEHAI OIAEGT Oii EM~`"~ H-SIGNAT~ ~ NAME OF EMBKMFR ~i eow w?s cwKr[D ~ UCENSE NUMlER ~ -~,C Fr~d ~ : P ' . ~ TMI CERTIFICATE RECEIVED OR RECORO ~ B ' ~ January 26, 1572 ~N,u,, ~ A n. n. ` n = - ; 232957' m:.. t certify t6at thi• ia a true tr~ascript of the informatioa on tae dea~t,tecord ~irecorded in thi~ oH'ic~. ~~.,-~t-, i^~~ - EL~~204 185 . : _ - ~~~i o~~g~ Atteat: . .w, • Re~i~tr~r oE ~ ~A"~ ?5 1972 ~ Sw~ ' ~ Dated ..................................................................Tov?n of...............:i~~:`~1~ j ..CrODA~4 Fi3.~ .o... ..wi.. ~ . ~t(~.. ~ . NOT GOOD WITHOUT SEAL OF CERTIFYING OFFICIAL • ~ ~ ~;~1`' << , , ,Y:~ N - - - = ~ ~ ~~.~~=z.~, ~ _ s =~^'~~.A~~~~~