HomeMy WebLinkAbout1296 ~ f/l[ IN WI1H 1YPEWR11tR OR lEG1AlE /RINTING f
COUNTY RECORD STATE OF IItINOIS "'F
- - - ~ ~ NUM~fR O ~
1J
OECEDFNi'S A/ MEOICAI CERTIFICATE OF DEATN REGiSiRAT~O tEG~STEtFO
•IR1N NO. ~ /1V OitTR~CI NO ~O NUM~E! 12
I.•PIACE OF pEATH 2_ USUNL RESIDENGE ~w~..e e«eo~M ~..ed. 11 .wt~.~~~.ow, ~evd~wc~ 6~IOr~
~ iiuiro~s b. cou?+n ~~ilton sr~tE I11311ois ° co""'T Ha~111toYf°"'~"~~
~
0 1 _
o c. INSIOE cwporole /;mifs ond :n Giy. Villaqe. or Incwpo+aled To.n c. ~ INSIDE capaole I,~nili ond ,n G~ly. Y.IToye. or /ncwpprpf~ ~pvn
McLeansboro, Illinois McLeansboro, Illinois ~
^ oi d. Q OUTSIDE cwporole lienils ond in e. IENGTH OF SiA d. 0 OUi51DE caporale lien~ls ond in e_ lEN6TN ol !E Ip NG
lo.ruAip now~ . . . . . . . . . . . . . . . . . . . . . ~H ~c « ~•t IornsA;p no/ne. - - - . . . . . . . . _ . . . . . . _ At h w td
:u Rood Diit.id No.. • • • • • • . . . . . . . . . . . . . . . 1 C18 Rood O~slrid No.. . _ . . . . . - - - - . • - • - - 8
B $0 1. NAME OF HOSPIT/~L OR INSTIiUTION 9-'NN6iH OF S~A 1. RESIUENCE I~DDRESS (Sl.ee~ L No. w R.F.O_ ond Posl ce)
~ o~
201 MeadoW Hills
C =N A_ 11 wt iw bsp~Id w~nst~l~lion, qi~e S~reef i No. or R.F.O. end ?ost O ice McLeansboro; Iliinois
aj q. D~d dKedenl res:de ON A FA~M! YES ~ NO
^ l. NAME OF s. ~~~~St~ b, ~?.aoDtE1 I~AST1 4. D/~TE OF IMONiH) IDwr1 1~ ~1 '
OFCEASED DEATN
n Francis Monahan Ma 6 1 66
S. SEX 6. RACE 7. MARRIEO. NEVER M/1RRIE0. 8. DATE OF BIRTH 9. /1GE (in ~eori N~- ~
E-- I WID~WED. DIV~R f~ (speti/y) 6:rlAdo~J rew~w~ e~~• war~~ r~r. j
J e White Marrie~d 8- -1901 ~i ;
F u~i ~Oe. USUAL OCCUPATION IOb.KINDOFBU5INESSORINOUSIRY 11. BIRTHPIACE (C~fy ond s/a~e w ~we:gn to~nliy) 12. C~~iIMW rAO~
I f T
c, Truck Driver_ Retired Chic o Illinois
~ I l. FAiHER'S fUll Ia. MOTNER'S FUII
j NAME M/11DEN NAME
d P aul J Monahan Minni~ Her?tett
r' LL IS. Wos oeceosed ever in U. S. Armed Forces? le. SOCUL SECURITY 17. INFORMANT
O (Y~f, p, p/ y~p~w) lG:~e~or a do/es d~e--.ce) NUMBER e. SIGNATURE -
, Q Hallie Mvnahan ~
C/~USE uZ+ '~O AO 1, ~2Z~ ~.17 h- ADDRESS c. REIATIONSHIP TO
OF DE/1TN ~ -
~ ~e. MEOIG~I CAUSE OF OEATH MCL9AYlSbO1'O~ Illinois °FW~~o
i ~ ~AtT 1_ DEATH WAS GAUSED ~r. (Eneei o~t~ o~e covse pe. ~~~e /w (A?. ond (C) 1 INTERVAI ~ETWEEN
0 IMMfOIAiE CAUSE (A) IE COU ON . EATM
. ......Myocardial Infarction_..._..--------..~a.eo~T~us...:- - --..~~~d.---
i N . . .
z-_ p ca.~drr:~~. ;t a,~,.. CtERK CIRCUIT COnRT ~
Z gore nx fo due ?o ( ~I
•~;~h ORO YERIFIEO
~ J eheo6o.e1MMEDl/~1E r ..............Ar.teriosclerotic CY Disea~r s•
~ J?'--~~--- -
",~SE - S~ 19 8 si AH
3 Ihe UNDERIYING Ld~• ,o (u
~ Vi ceuu Isst. •
/ARi 11. OTHER S16NIFIGANT OHOITIONS CONTl1{Ui1N6 10 OEATM {UT NOT RElATEO 10 THE 1ERMIHAL CONO~iION O. AUTOISI~J
~ 4 N GIVEN IN ~AtT 1~A). .
~ ~ Diabetes Mellitus
~ I90. OAT[ 0/ M[w~TpM. AM~ 19b. r~~ew ~~MS~~a{ OI M[~~iNw
[ N
LL TES ~ NO ~
~
~ NOTE: If •n injury w~s ie~ol~ed in this de~tb, fhe Coron~r mus} b~ eoti(i~d.
<
oWC 21. I Aere6f c~rr~ir 1Aof I onended ~6e deteosed Irow ~ . w . ~o ~ , 19 , thoe l/osr saw lhs deceoied oM
_ ~
i oe~,=(~_ . 19~, ond deoM occwred orli s 2o p. M.. 40~ ~Ae covses ond on Ihe doh sldd o6wt.
- Date Ilfmps l ersse :
_ o Signelure? _ . . Donalel. L. - -Mit.chell . . . . . . . . . . . . M.o_ . S,~ May .9-, . .196.6- - - . ~ . 3~17b.. . . . . . . .
~ ,wd,~,s. l,l~.0. East . Market_ . Street, . McLeansboro., . .Illinois Pho~e. 6l.~.3-~3?? _ _ . , . _ '
` ~ 22. OISPOSITION: dUR1A~-REMOVAL CREMATION Dste. 5w~.~1.96 23• FUNERAL D~RECi R
: ~J'. B. Gholaon_ . . _ _ _ _
CEMETERY IOOF SIGNIITURE
f' ~ ~ooRESS . McLeansboro
. . . a . . . . . . o~~nas lKense
~oc~noN ....M~I~B.au~bQx'4.s..Zl.i.~o~.s....._... .....Il1.i,zQi~~
...................~~6~3----~-.. -
- ~ 'H~ AUIHORIiY
1 E~?F ICLINO/S 24. Rece:red la (Siqned) ~
,~-~..,SS May 9, 1966 Velma Sims a
~ LOCNL REGISTRAR
- - - -
_ • ~ ~ • st, c
~
' ~.~nlllf!ti~ _ i .
^ .
,,I~.~`; : 4 `
I H~REBY CERTIFY that the above information was taken from the death~; ~~°••.f%)~=~,, • ~
record of the above named decedent which was f iled in this offiee ~f13~ l
r
~ accordance Mith the Vital Statistics, Act. _~ti . f.. t~ ~ r_
~ - .
• }
, Signed ~ . ~M _f ~ ~ - ' ~ '
Date Record Filed lqG Title d ~Li•i~~"~~~4C~o
~~,L i-
• , _ , ~ '•~J.... , i :
Date ~ 19 ~ Address
_r ; .
< ' OOK ~VU WtGE ~ ,
- - _ _ . : ~ -
""z ~ , ~ -
A ;