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HomeMy WebLinkAbout1312 . . - - 238~_ . ~.~:.._a~ - . : . _ _ - - - ,~3~ c~~ s , . i DISTRICT OF COLVMBU DEPAATMEIA' PIIBLIC HEAI.?H ' ~ CERTIFICATE OF ~ 6 0 4 0 8 ~ H~ _ } tuc~ ot nutn ~ NA?IE OF NQ6PlTAL OR INSTITUTION (H wo~ is Aw~itK ~i» Miwf ~lna~ t w toq, - - wplb MluLlaqsou. D. C. ~ ti~ . : . ~ ~ ~ • . ~ : ~ ~ ~ - . ~ . ' ~ ~ . . ~ 2. 1lSVA1 1lLSIDDfCL If'lurs dere~wd firef. 1 i~utitrti~w: Reritew Otl~ ~RW~) ~ • S~ATE ~ b- COUNTY a CITY, TOWN, O~i ~ATION ' ~•tt .~iti- i-- l~'. ) ' ' ~ a.ThFlT ADDl1ES5 r ` IS RESIDENCE INSiDE~Ci?Y U14I75T 1. IS HfSIDClICE ON A FAR1t~ i' \ \ ~ . ~ ` tl ~ t' 1 ~ nrl ~ 1~ • . ~ ' ~.V ~ YES ~ ~ NO 0 YES ~ No ~ ~ ) MAMt Of Pi?~t_ Afillft Ld { DA7E dfow~A D~y Yerr K G D[C[AS[6 AF' ~r... ~...:.ri ~ ~ 1 ~ e 1~ ~ L l_ _ t? c~ ue~ r H ~ : ~ ~ ~:OC 6. OOLOR OR HACE 7. ruain ~ Nma ~waw DATE OF BIRTH 9_ AGE (/w~tr r, is u~cRa 1 rsna 11 VAK~ 2~ HLL ~ ~ 1 t Airthdoy) ! ~ . w ~ ! ~ v Mnoro ~t~ - f.- ~ ~l _S XowtAa Dsp /fow~ /Uiw. : l~, 4. ~.t O O ~ i - , ~ , Iro. l7SUAL OCCI/PAT10N SGit~ 4i~d oJ.w.4 Juws lOb. CIYD OF Ht)SINESS OR ! 1. BIATfiPLACE 12. CITIZEN OP WHAT OOUNTRYi I , lv,.~ .w.t y wrliw~ lU~. erew ~J ered INDUSTRY (3tat~ or /oni~~ corwtry) ~ l ^ ~ ~ { ,~,~r- c; _ r,., r, J ; t7a ~ATHE7i'S NAME t / 13b. )AOTHER'S MAIDpi NAYE [ 1~. NAME OF SURVIVING SPOUSE , ~ ti~~.: ~ l!~t: l( t~ i i~~~ l~~ lol~ ~~'.v~C ~r~~. ~ l l 1 ~ M~QS DDCEASfD EVER 1N U. S. ARl[F~ fC~NCESt l6. SOC14L SF7CURITY NO. 17. nQ011lA11! 1 RSLA!lON~/lIP TO DSCSASJ[D ~ fw. w rwF~o~ew) Yn. I~nt rv, data o/ wrsics) ~ . . f ~ r ~ ~ t ' l`'~ ~ ~ t' • ,+i • ~ ~ ~ _ 1S j,~ 1/ CAUEE O~ DEATH (Ewtn on/~ owe cawe g~ liwt Jo? (6); awd (r ~~tu~u ~rrmv ~ VAFiT i. DEATH 1NAS CAUS£D BY: r~ ,l e?carr ax~ wre ~ It~1MED1A7E CAUSE (a) ~ V~t~ ~j l t1 1 L ` 1 f - , ~ . iT.lUC1E COWl~Y L ~ Co.~~tp.., •~y, vhKA prt rut ~u DUE TO (b1 ~ ~ '"~"'d~:= } REC~RO VER~ IED ! ~w rar~e Ins[. WE (C) ~ ~ 1•AItT 1!. 0771ER SIUNIt7CANP OONDI'f10NS wxnnvr~aro to ~ara ~vr n ~x ~~mo~ utcY ~x r.at ~(e) t ~ 1 1~ ` I ~ V p ~ ~ L~ r' ~ ri ~ ~ ~Y~~ !9. PFAF~AIAE~D?SY Y~ YES N ti C ~ 0 ~ ? t: ~w M r w~~ AOCIDCNT SU1Cl~E HOl4ICIDE 20b. DESCRIBE HOW INJUR7 OOCUARID. (6wtt? wurr~ o/ i~/~ N PtK f o? Pa?t ll o) uew !I.) r ~ r ~ ~ ? ? ? f-s A~~~~~~ owf . laY. a+? INJURY e. w. M w. ; xd. IN~URY OOCURRED 20~. PLACE OF !N)URY I., u o? ~bort Aow~, 201. CITY, TOWN, Ofl LOCATION COIiNTY STATC . - Jorw, /o~Ivry, Mrost, o~c~ OlI/., Kr.j . ~ • ~~Y ~T O \O? rbNi ~ . . •yt ~T ~YUIK } 1~. !.w.1d a. a.n.~.e l.e. t 1. c ~ S~ ~ a ~ ~ o.e Md ww an...n , ~ ON~I oee~~d at i r ti oa daN awd aLo~~i ~sd. tM 6M1 d~1 he~NdY~. tea~ ~ oarw~ ~1sMd. ~ 120. QGNAiU11E~ 2Zb. ADDHt:SS 22a DATE SIGNID / ~ ~ '1/ 1 a ! ~ . . l,t. D. ~ ) C~•c- • I J ( Gl,'. ~!I[!~ U :J~l !UP(AL 3b %lTE 27e NAME OF RTl: Y 011 TUHY Z.ld. LpCA ON (C~~~. I~e.., w ~urwf~) ~~f i ~ ~h14lATIOH 1 ~ r MtMUVAL `1 C~ y•~'~.. ' • C~ ~ ~L L. M IvNf:NAI y E~ . ~ ` : . ~ ! ~ , ~ ~ UNDCHTAC SlGNA RE 25. UNDCATAKCA'S ; ADDRESS. _ f7 ~ . - , ~ l. LuC~I ..LJ i- ~L- N M'BF71A~~ ~ June 2 1960 I certify that item ~16.;SoCi = Sec. No./ ould read 578-22-99G6 fU~A~CS• ~ •.hi` • ' i ~ .•T , ~ _ . ? . ~ . a ' t~' f.~ ~ `s~ )C - • ~ . ~r. ~ -s ZT:. ~ -V ~ ~~1' 4•:- L i ~ . - ~ -c - - _ . :~Q, `'?~ceased- Nife ~ - • - _ . Date I~sued! JUNE , . 9 I~~ ~ This is to cer~'ify that'~= ~."r •~~s~•,xrue and correct re~~roduction of the orginial certificatt~ ~`~1~~~1'n.'~~der with Lhe ~ital Hecords ~ Divison of the Department o~'~::i~~Q~t•~~s ~fr qs, Di "ct of Co ~ bia. ` : ~ i~ t / ~ i ~ R ~t~b 13~9 ~ ~ ~0~~ ohn Crandall, Chief ~ ~ vital xecords Division - ,r - - . j ~`C ~ . r, ~ '~`~.~~s ,`°,~-~~s