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HomeMy WebLinkAbout0161 , , .r--...._. . CQ.~:tiEC~lCUT STATE DEPARTMENT OF HEALTH NO 5562'7 • Public H~altb Stalistica Seetio~-lia?tforJ~ C~OMltl~lYl U.3.A. ~ ' A~~ ~erliiiccxle of Death Legul Fee: al. D~ A ~1~ - I. P~~ee o/ Dcwnt: (a) Sate ot Conneee~euc 2. Us~ u f;~<<e~:xce w Decs~sso: la) Sut~ C~07~ . (~Ap~r lb) Cnuntr ~ (e) Tb~re (b) Co~r.tv (el 'Ib~~. . :.:;~t (d/ It Resldewee InrWe ~ ti Clt~ or BwouRA Liwlt~! r ;N ,.~cv Itac~nl ~,:-w'~~~t~E,~.i ' 1 J ~ . . ~ Idl \ame ot iioepitd or~lnstiwtion 1el Sir~.~t Numotr ~N~~~•.~ j v~'~lfd ~ No ~ (it not in a hospit.l or iaatitution Cire Street .~'u• lif rw~l. ~ivc location) y r/, YM. n•~ne Cltr or or loeation) . ' ~ ~'J ~ - ? . ~ ~.ot~ • ~'a • ~ ~h. ~ ~i ' ' ~~N . ' • . _ i N• c or (F'~nU .at~~dtri ~l.ast! ; Sccullttr NuMUIt Dccs~sso y~r~~~~? `•f ~ (Tsveor orintl !~_lkiljlss r-==-=-_----~--~J~ - ~~~~~YH '~~~~SffQ~i ~ . -rtEpl tTsN r+.~) PERSONAL A\~ STATLSTiCAL PARTICULARS • • • -i:~`..:~ C.use n? Du~y f te~ esy., ~ b: (~1(N ~e~(~1 { i. S~; 6. RwCi Z. ~dARai[O Q:iCVEa :ti:.:=.!'^ ~ ii P~1lT 1. D[ATN Mt~~ 1li~iJ•~ ~••.s•.• IMTqtA6 t~~~a~n C~u~tit•-•••••''• ora:.H. f~I['91P ~ i ~ W~cow•r.o ~j i~svo~cw . ORATN 1 i. Sr a7waueo. Wioowe~ oa D~voa~ia, e?rr DAw~~sx \wx~ oc p ~t W~n oa Hvs~..r+n !i ~IUF`j~t'~E~ ~II~~C~~~/~~. ~LQy~I .!6 ~/]eL. _ Henry Bohn ~ ~i Dwrs o? l?loatb) (Day? (Ycar) t DUt TO (~I AT ~,rr Drwttt ~ r Cunditioru. ~.u~Sti 29 1jv5 ~~if •ns. rrhies ' lY. DwTS or B~aTU Aec (in yeors ~t undcr 2 vear ' if unde~ 1 day ;~"'e tise a~yTRFjC~ANI PL AN~ .2J~js 4 - ~ ~~bove tause Iast birtAdql~ Months I~?~ys ~ lioun ~.1ins. I(~). stwtEnR the underlp• Dy= Tp (e) ~.2-21-1.~97 6? # ~ j ine e~use ~ j last ~ 11. HIItTNn.Ats (C~ty ot Ww/n) (S:ate or furc~¢n countr7r) ~ "~s~r 11 OTH[t SfCM1fICANi CONMTN~M6 COMTRI/YTIIlO W~~ I n i• + !I D~'wTll tUt NOT RCLAT[O ?O THi TitI1lKAlr Z1tltA ~`•E':~J Ha~n ~.027.1@C+.1~1.. !i Coxo:rwr? GIr~N tr P~sT I(~). ~ ~~sY IZ. USUAb OCa:UPA710N (Girc wlnd of v:urY. .ion! .inr~r.z mrc of Fwro~rpT worain¢ litc cven it rctirc~il J Ye~ ~N~ ~ ~ :~Y'2Csi.1~81 :1L1.2'S@ !1 2t. ~vace~r Retc~~t+s To Conanow~ Rstoatn IN itsM 22. (S) Iwousirt • u ~csicess ta) ti~me o( ovention f~) D~t~ ~erbnn~! ° P j.~ ~ii? ~~.0~2~: u1. ~ ti. (~1 \Yws D2CEASED w VEteswK! Ycs or i+~ r++~=TID OGRAp/7I' ~ ~~~~~J (b) I[ ' (b1 T~ws qr lw~car ~ jav. ¢~r~ a•ar 25. Ial ACCSOGNT SYICID[ HOAtC10t ~I. r«r ~ v~~e oT sn,p Q O ;i 11. NwMe -`'r~ ri! g0;'=~7 ~c~ in~vR~ Occu~uo Idl Ih.e~i or In~uatr (t.o-. iw ~r ~Nr! A~wa. ~ ri ty or ~r ie:...~n c„~ ::r, i:' t~'h:te ot ~Toc K•Aife la~t~?I. ~tr~~t, yle~ i1/I.. ~b.) ~ ~ ~ tCw: r- a: ~ IS. li~rri~?c.wc~ Uii:: :C`:d1 ' +i y _ ; 1 Mw~acx c~;. - c i~ci Cisr Tv..~, ow i.oc~r~ort CouxTtr Sr~rs ; ;1 „ i~. NwMr. ' ' A lia _ a ~~r~ ; r (Gcy or ~o`va) (5tate or tua..z~ coun:ry) ~i I ` ' I 1 r` t 1:. IItkns~~wce `.iC~•1 Haven ~.OYl.'1{' ~i,~ ~~Lt~ I~ (fl Drsca~~c ~~nw inivar Occviuso. lF•rctr• nn[r•e ~I If. IM~ORNAM7~! .IwHC a Pa•t ll of itrw ?iI'S..~iheste: lfl.~'^?SZu1St~--: ~U='~1~•• ~i 2G. I HEREBY CER?IFl'. tA~t I attendad lhela~e~ad /~as ~ ; 11 If. Bvaut. ~~twtt~.` ~=Rexorw~ :,~te_- 9-1 ~ ;9~~fi~ ~i ~ ~ 3 » ~sS'~ . to ~ ~eZ9 1! d.a~ ~ ~ ( ~'s ~CY_v;+c :~11. S~=nt e i~ .i._. • .w. a.......t .n.~ on 19..~.7` ~ F:aec Z'T(l: t~; ~'g~il . V~[7?'~ Cj'i,1CUti and that death is a~NJ to hace oeeurred on •1 ~ _ 2Q~.fww6 or Errw:.~tK tr Bootr MA1 ~~:sx:.a~[~ ~ :.:ccr~r nu.^..~:r ~ l~ ~ m- 1!_` ~ .a' .S~ 11~ - Z ~T - cvw:C~c Qt PNTACtAN Lu ene R• ~~er ~i~ 21.$!G~tATI'}j.(1~ f~!"~L}:EF ui~C~--1:~ r.~ti.~=, -1 ~L 'T. Ha:-~" ?v i. ~ .i , %y? ~ , Ccc ~ g _ . ~ ~ -te~ne: 31Dfi'D~ r. ve.~asaer:,~~..:ec~f~ r !ct" ~~~~V . . A•idr.•.s ~~Q/Z~~G D~f! TNl$ 'IIF1C~"E ECEIVZD. FO RECOHD ON ` i _ r~ Rc~:~ar~u¦ i~ .~"U T $1 ~ lSo"5 ` i ~ ~ t A~ ~ ~tdQ~= ruk?r-v • ' ~ t ~ , : y ~ • • , . ar = 1 eertifp-tii~pihi: }_1'1~_ ~[Y~li pscript o[ ine inrormation on the deatl~ reeord u rteorded In t~i~ o~ie~. ~ ? . ~ r t ~.J'~~~' - 4.~..~' _ ' ~ Attest: - . . . . . . Re~i~trar of Vital statiNiu ~ . ~ - - ; ~t ` ~ Dated .......l~.g.ep..ttF'~b..Qi.j,'...Q.F...~.,9.D,~..........Town of 2~8V9I1 . 2 ~ NOT GOO:i WITHOU i SE 1L dF CERTIFYi• OFFICIAL ~ Furm V.S. 1bC ~ . ~ _ . s - ~ N ~ . ~ - . ~ . - . . d ~ V ~r{ Q,v~Vr~~V yr~V~C al~ ~ i f~ ~ ~~~~e''~1 _~"_~~r"_ ~ "9 {.~.T.` ~.1~' v.~.f ~ _ ,e _4.:f .:3 ~ ~ ~ '