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HomeMy WebLinkAbout1288 ~ . ~ r . . . 3 OHtO DEPARTMENT OF HEALTH. ~ - ~ ,~4Q22 - Rs~. Dix. No. DIVISION OF VITAL STATISTIGS s"" F~i` } p`~'~' `t`~. D1c. CERTIFICATE OF DEATH ~s~unr'a No. ! DECEASED-NAME Firrt •Ui.t1l~ lrtt SEX OATE OF DEATH !,?to~~b, Dar. )'t~~) i JOSEPH AL1?YACEK =.Ysle ,.15 1Is 19T1 RACE ~'y%f~. 4a•e, r..e•ic.. AGE- L,r UNOER 1 rEAR UtrDER 1 ~~r o~rt or s~ii~ ~.::o.r6, D..~, COUNTY OF DEATH iwdi+w, slr. fS?etilll f7r+ii1 .N~i. Dhr Hor~i .1liw. Y~''r s.Cancaaiaa s.. ~1 s~. s~_ s.l Dec 1889 Cu aho a dTt, VIIIAGE, OR IOCATtON Of DEAtM IHSIOE CITY 1IM11S MOS?~iAl QR OTFlER INSTIiUT10N-NAME fl/ ~ot iw ~itb~r, tirt itrte~ ~wJ wrA6n1 !S?tci/> >n e~ wo) ~s. Psrma Hei ts 44130 a ~e.~riatocrat South Nnrsin Aome Inc. STATE Of ~IRtX /1/ ~ot iK US.A.. wr~ts CIi12EN Of WMAT COUMTtT MAlRIED, NEVER MARRtEC, SURVIVING S~OUSE (If uiJr, jirt wridew wat) cer~f?~) WIDOWED, DIYORCED (S?sriJ~! ech sl ~akia o. IIS~ ~o.llsrried l[arie Ko~ar SOCIAI SEGURITY NUb~6ER WAS OEfEASEO EVER IH U. S. AfA?EO iORI'ES? 2T3 03 2472 A rr~,, o? r~lwou•w1 No ~u,~•.::•• ei ~•f o~ f~•:«~ - ~SU~I RES:DENCE IIo. wHERE DECE/\TED USUAI OCCU~ATIOH IGi?e 4iwd eJ tr~rk dost larri~t ~~~f ~J KIND Of WSINESS O~ INDUSTRT lien s Clothin Industr OCCU4R D~tNTM ~~orki~s liJe. tve~ i/ rsfi?rJ) railor 1~. • g 7 IHST~iJT10N, GIVE 1Jo. ~ES~OENCE tEFORE ~ESIDENCE-StAiE COUNTY QTY, VItUGE OR lOGT10N INSfOE C1TY tIMITS STREET AND NUM6E! .,oM~ss~o?+. ~s~«~~,r~j~?~~ 5618 Merkle d~enue ~~a. Oh10 ~a~~Shoga ~~Pma 44129 ~~a. 7ee ~a.. ' fATHER-HAME Fin! 11i//!s I.nt MOTMER--MAIDFN N1ME Firt! .Ni.fllt Ltt ' ~~s. Thomes Rla~acek Deceased ,s. Barbera Ruzkora Deceased ':Sra.t o~ X.F.!~. ~+a.. ai: es s~i!f_S': =tctt. ziA; ~ IhFORMANI'-NAME ~u~:~~+~ ~aESs - Yarie Hlavoce~ 5618 llerkle Aven Parma Ohio 44129 T49 442~ - 17a. - x fART 1. . DEATN WAS CAUS~D BY: (ENifR ONII' ONE GUSE /ER IINE fOR fol, (b), AND (cil ~~~XIMAiE INTElVAI ~ iWEEN N ET Ml EATH Z l t. ' ~ `t tal T ~ ~ ~.Z..~ IMMEOIATE CAUSE ' ~ `~r WE TO, AS A CONSEQUENG F: W Gndifiawt, ij ur~. ~ riitb s~~s rise to (sl ~ ^ n- nw~rtdiatr tirrs f~1, DUE i0, OR AS A CONSEQUENCE OF: it~tir~ tbe rRder- ~ l~i~t tarre !mt (c j f., PART 11. OTNER SIGNIHUNT COHDITIONS~owditio~t torJribuJies !o dt.:tG brt Rot relalyd fo tu~ur grew is oarl !(a) AUTO!SY IF TES utre hMdiRdr ro~iidurd ~ (Yn er we i+ /rtn~riwixt ~~rrr o/ deatb i ~ 19an0 l9b. ! ~ ACCIDENT, SUICIOE, NOMICIDE, OATE AF INIURY HOUR NOW IN1Ut~ OCNRRED /Ests~ /ut+rrt oJ lRJYI) !1t pJ1( I Of p0~ II, itt~w 18I ~ Ot UNOETERMINEO ISperiJ)! I.No~t~, Dq, Yta1 I f Q 200. 206_ 70t. lOd. INH?tt AT WORK ?IACE Of iNIURT At b~wt, /ar~r, t/rer7. Jattor~, LOCATiON /SJ?~s~ o~ R.F.D, wo., rilr or vi!laat, tt~te, sip) ~ W IS?scill )es or M) o/fur Mdj.. ac. fS~rrilll :Of. ~v } CERi1fICATIOti- .Nowfb Uo~ Ytrs .Mottb Da~ Yt+r MiD LAST SAW HtM/MER 1 OID/OID NOT ~EAtN OCCURREO A~ lbt p1a[t o+~ ' IMY~ICIAN: ALIVE ON VIE (MOU[) tbe daJe, ~ to 1 ATTENDEO TME ~,f}~~ TO tb D~f Ytar AfTER DEATH. 1O=5S tbt iett o1 wf ~..r-r• I ~ kwomledjr, dre Io 21a. OKEASED FROM IIA. ~Ic. n( 21d. 21~. ~1 M. tbt rrrtt(rl tldtd. CflilFiGT10N-COlONE[: Oit tbe buil oJ tbe rrrsiwltioA Hor? o! dtafb Tbt dtredtwt uat prowor~~sd dtid o/ ~bt bod~ aed/or tbt iwra~tir~t~v~, i~ a~~ opiwro~, dr.ub Mowtb Da~ Yra H~rr occrrrsad o~ tb~ d~r .:~d dYe to tbr c~rul r1 u.red. 'n na_ • ~V- sh z~e. •N 1~1.(, 7 ~ ~ ~ ~ CEtTIF1ER-NAME (T~oe o~ ~riwfl SIGNAiURE D•r•• o? r;rtr DATE SIGNEO ?3a. Bel Rivera~ D. 236. A~ :L~r`GV` 23c. ~ MAIIING AODRES~CERTIffER STREEi OE l.f.D. t+f~. t1(T OR VIIIAGE STATE Zit " ~,a i"~i'i3~, iianison a~caua i,a.~e~o~~ Li~io 4~i~7 52: ~`.S8 ~ WR:AI, CREM4TION DAIE KAME O~ CEM~i£itY OR CRE,WAfO?T LOCJ1ilOH ICit~, sillw t, or roraf~I (Sts:t1 rsD«~~,~ 19 Lial 1971 Brooklyn Deight~ Cemeter Cleveland Ohio 44~09 ~ o z.~. Bnrial ~.b_ , .<<. - - NAME OF EM6AlMEt (UG NC.) F'E UtRECTOR' ~I " E (UC. NOJ ~ ~ ~s_ Rvbert J. In~an~8T3~ 26. l 3133 38 ~i ,c ' FUNERSBUer SADDAESSeTBI~ HOID@$~ I~C•~EfT NO.) ~ ~ (GTT~ (STA1E) (ZI?) ~ ~T . ~ruia 4St11 3tem his Avenue Cleveland~ Qhio 44144 351 4625 OATE IEC D~T RKISSUf'S S~ aA~ J/E lAATE tERMI~ ISSUED SICNAiURE OF [ERSCEN ISWING ~EItM~T Dln. NO IOC~t tEG. ( ' - •i..=a . ' ~ ~ ~ • ~ j i ~ ~ ~~l ti`~ ~ 'y ~ ~ I ~r 1 ~ ~ - ~oEO i 1 NEC~Y CEY i'iY .;r r~.,s ~s ~ _ ~ : ~ . . r A. ~ FILED AMD RECO r..r.;.: cc•rr o~ - ' ~ ' _ ~ . ~UCIE COUNTY Fl _ :!t: ~ . - - _~y,.~. ~:~t ' t~ . . gT• ROGE PD TRAS L~ ~ '.`r=~r:._n~ t ~`~i~' ~1~°~~ . ~ ~ K ~R f `11 COUaT ' . ~ : ~X ,r F; i ~ , . • RECO~~ ~ ~ ' M~Y { t``~; ' ; j 12 43 PM' . . . : . ~j Z~ 1Z _ _ ~r:: ~ . - - ~i. .•'p- - °y': . • i • --G , - • - _ ~ ~ ' ~1~'~~. : ~L4U22`?' ~ ~',RF~;~: ,,,r ;.r ~ * ;',ti` - i ~ ~--4 R ?/ITN:SSMT FtANp /Wp ~ ~ __~~~T~,a~,~~~, Bo~K~07 ~~~~128~ . , - . -b~