HomeMy WebLinkAbout1900 ,
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240'703 c~x~cA~ oF n~rx 5~.~. N~
DtBTH NO. M;lilia Dia1. No. Custodian i Na ~~0~
i. 2:AME OF (Eird) (Middl~) (Lul) 2. DA7E^ (Non1L) (Da~) ( ~at)
7yp~ et Pnn1) ~l ~GU L1iN~ ~iJ + DEATH SraC 1CYRDrai~ 1~ 17 /'G
. PLACE D ( eunl~) ~ USUlU. ALSIDGIiCE (Wh~~~ d~c~a~~d ti~~d. U ia~titution: ~~wd~nc~ b~lor~ ~dmiyio~)
DII{ALB ~,a,~ FLORIDA ST.LUCIE
Cit~ er lowr~ In Ci1~ Limit LENGiH OP Io Cilt L'miu LENGiN OF
~ ~y Y~~ No Q SiAY (is ILi~ ylac~I
DECATUR ~ Y•• o No SiAY ~ia 1~ ptae~) c;,, FORT PIERCE 33450 ~ ~
Town
Nam~ oi Ho~A• e? Ia~titution LENGTN OF Stii~1 Addr~ii
or A.F.D. aed Eo= No.
VETERANS ADMF1~lISTRATION HOSPITAL sr~Y
5 DAYS 2714 Cd.EANDER B'LVD
S. SEX i. RACE 7. EINTHPLACE (Stat~ or for~iqn touatr~)' CITREN Of WHAi ~5. lS AESIDEH E N AAM? 16. BUAIAL D E
COUNTt1Y? AF~IOVAL Q9 7 ~
M I W GEORGIA I USA Y•• o N~ a I CAEMATION n I-~ ~I ~
i. DATE OF d1RTH 9. AGE (Ia T~an) IF UNDER 1 YEAA IF UNDER 11 tiRS. NAME OF CEMEiEHY ~LOCATION (Ci1~ or 7ews) (Couat~) (Sut~)
lut birlbda~ Moat6i D~*s Heui• Mie.
4-2-15 i 5~ I ( i I PAI.M IrID~iORIAL CII~;TER~ HAZELHUR~ST-JEFF DAVIS-GA
10. MARAIED~ NEVEh :1ARRIED J i11 Marri~d o~ W~dow~d Gi~~ Ii~m~ of Spow~ 17. Et~lDllli~7~'S SIGHANRE ~ ~ I LCETISE IIO.
wIDOWEO i'~ DIVOACED p y G ~ a
SEPIIRA7ED p DpROTHY ELLIS
ll. USUAL OCCUPA710N lGi~~ kind e! work ~IIND OFlUSIN~SS 09 1~.
M--~U1N
1~:~S~P~~~~•~ ~~••~~k~v u~•~~~•a~`STATE DF~T-AGRIC THOMA.S~dAINWFtIC~iT FUNERAL HOME
12. WAS DECEASED EVER IN ll. S. ARMED FORCES? SOCI1lL SECUHIiY NO. 19. MOAi1CU1M'S ADDAFSS
~Y••~ES• ~~~••n~~u'~~-~-42 ~ 1
2-~••:~•~ ~ 256 09 8730 HAZII,HURST GEOBGIA
i7. FA7HEH'S N/IME Z0. INE09MA!(T l~laBoaaiip
~OII. II.LIS SR VA HOSPITAL RECORDS
l~. MOTHEB'S MAIDEN NAIl1E 21. INFOAMANTS 11DD8FSS
Rr.BECCA COOPER DECATUR GEORGIA
22. CAUSE OF DFJITH [Ent~r onl~ on~ c~uw p~r lin~ !or (b), and (c).) PLEASE PiUtii INTERVAL BETWEEH DO N W9J7E SPA
PAAT I. DEATH WAS CAUSED SY: ONSE? AND DE/lTN I. I
IMMEDIATE CAUSE AORTO-FIIrIORAL THRC~OSIS 3 DAYS
Z ~ 3. I L
! ~ coaa,~~ee.. u.e,. DIIE TO (b) T~~''~OSID AORTIC ANEURYSM ~ 3 DAYS
~ O..t~.6 pa.• ds. ~o _ I s. ~ i.
, y. abo~• taW~
~ K ~~~hnQ th~! YL4..- p~pg~,~OTIC CARDIO VASCULAR DISEASE__~_ YEAR.S
{ ,.:n~ cavs~ l~st. DUE i0 (cl
~ PAAZ U. Olh~r ~iqw6cant coadiAOO~ conlnEulinp !o d~als bul oof n1a1~d to th~ t~rmin~l di~~u• coadi~ion pi~~n in P~A I(aj ~ 2~. AUTOFSYT
c~a I Y~~ ? No ~
~ H _ _ _
21. ACCIDENT O'p~ACE OF 1N1UAY (~.Q.. in or ~bout ~ INJUNY OCCUAAED -~A
~ SJICIDE [;~hom~. tarm. (~ctor~. dn~t. ~ W6i1• at Work 2s. [ e•~.br cMil~ thaf~l att~nd~d th• d~c~u~d !re 2
~ L' }{OMICIDE Q oHic~ bldp.. ~IC.) I Nol Wh:l• ~t Wcrk Q 9-~ 3-72
_i 19-,, to ~ 19__. tbat' u1 uv~ Ib~ d~c~~~~d
~ iCITY OA TUWN) (COUNiY) (SiA7E? 7IME (Moaiej (D~~) (Y~uj (Hour) ati~• oa 9'~ 3~72_ - 19 . a+d Wt
~ OF
INJUAY d~ath occun~d at~ Atm.. Irom th• uut~~ aad on Ih• dat• ~t~t~d ~be~~.
HOW DID INJUBY OCCUA7 2i. SiGNAiUAE A~Qr~~ er 7iU~
ROBERT B.S'~QTH III,M.D.CHIEF,SURGICAL SERVICE
2~ REGE REC'D bY LOCAL (2i~GISTRAR' ~ N~ Q ~ ADDRFSS I DA7E SIG:YED
9-18-72 MARY DAME D~UTY VAH DECATUR GEORGIA 9-18-i2
Ai~~( 5 3~~1 ~orpu epartm~nt o u iu 1
Vrtal R~cords S~rnc•
O~ Decatur, f~f~aib County, Georgia ~
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a ~
~ This is ~o certi[y that the above is a true and correct copy of
~ ~rC the certificate that is on file in 1~'ital Records Servic~.
~ ~
~ DeKalb County, Decatur. Georgia.
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~ ~a cu ~ ~ •'f~4c r" '~`j~•~2?,•n~ Signed . .
~ ~ f>~. ' . . 4 ; ~T Reqistrar of Vital Records
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~ ~ N¢ ~ ~ "`'~~~`~'I,''~- ~ SEP 2 ~ 19~2
J Q ~ ^S1~al,r;~F~11'tl,' ` ' Date issued
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