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HomeMy WebLinkAbout1511 . • . ~J q 2426~3 OH10 DEPARTMENT OF HEALTH R`R. u~u. DIVISION OF VITAL STATISTICS ~o. Pr~mary ReR. Uia. ~To. ReRiscnr's IVo._ ' 7 d CERTIF{CATE OF DEATH DtCEASED-NAME f;nt AGddfe Lr~t SEX DATE OF DEATH I.?lo~tb, Dq, Y~a) ~ U 'Ut ~ :zlli r~. %7lu.c:c1# 2. i'~[LLC RACc u'L;rr, Nr6ro, artri~r~ AGE- Lut Ur+DER 1 TEwR UNGfR 1 DAr DAiE OF ~itTH I.Nor~b, Dq, COUNTY OF C EATH ~tiJiwr. rtr. ISOtcil)! biaibd~ l~nnil .?lor. Urrr /lorri .Nis. 1't~r1 . L ~ :%:.i.~C.' So. Sb. S~. 6. 1V~~ -1 70. ~itl 'c~L Clit, VIIIAGE, OR IOCAiION OF DEAiH INSiDE CITY LIMITS NOS?~TAI OR OTME~ INSTIiU~ION--NAME //f ~s! i~ tifbtr, jirt t/r~~! t~ei awa~fyJ fSO~r+/1 7~~ Q? ~o~ Garfield ei ts ~~d. 4980 Ed rk r _ SiATE Of 61RTH I/J Not ir U.S.A., wwl CIT12fN Of WMAT COUNiR~ MARR~EO. NEVER MARlIED, SURVIVING SIOUSE !1/ ~riJt, sit~ wridtM w~f) • '°MK~r~~ ~WIDpy~fEO.O1V~0~R/CEO IS?~tilil 8. ~/fLLU 9. ~•,~y i0. I~1~:1/1~L~.(:(.C /1. ~ Q~j ~ 1~ • e SOCiAI SEtUR1TT NUM6ER Ww5 DECEASEO EVER IN U. 5. AU+?EO FORCESi ~7 I)"n. ro or rtkw~u AI 2+ ei. L~ se ^ayvr or l~«r o j'n irt! . A;S~DENCE 110. G/~"l/1~1 V • 116. I'iQI I l 4.V ~~IXJC 1 7 7 ~ 'vECEASED DEAIH USUAI OCCUfAT10N lGirr 4ird oJ ~~or4lo~e lrriws iwe~t oJ KINO OF WSINESS O! INOUSiRr ~ ~N ~ 0.4;~~ :/q trrw i/ rrrirrd! . . r.Otr. G~VE lJo. J. 1]b. S#P_Q,[ . '~~+CE 6EfOtE RES~OEr+CE- twTE COUNTY Gir, VI?IAGE OR IOGT~ON INSIDf CITT LIMITS SitfET AnD NUM{ t ACM~SSiON_ fSO~c' Ja or ~01 ,.o. U/u:~ f tuccz~o: a °.~P,C:t !lr~.c::ilr:lls ,.a. ~ee ~l 80 ~ d~ x~r/i Drci.ve FATFIE[-HAMf /~rrit Midd/t L~1t MOTME~-1MAIDEN NAME Finf M~ ~ l,~Jt . ~s. Lev.i.. ~ 7'~n~e~s~ ,b. U ~~Iza ?~~rti.l./.a • ' INFORMANT-NAME MAIIING ADDtE55 (St.eer e. R.I.U. ~o., c;r~ or rill~te, it~e, :i?1 ~ »a ,':n~s 13en~ m.in ' i'r.,i.~.st ,~b4~<4~ ~c~~~encu/t U~ve N ' ~R ' ' ~f4 2~ - rwer i. DEA7H WAS CAUSED BY: (FNifR ONII' ONE CAUSE /ER LINE FOR tel, (bl, AND fd) A?~Rp7I1MAtE INTElVAt 18. INIMfD1ATE CAUSE h erten ive cardiovascular nnal disease. DUE 70, OR AS A CONSEQUENCE Of. Co~di/io~t, il •wy. - u•birb aaae rire to S (b) ` i+nnrtdirtr c.wte (il, DUE i0, OR AS A CONSEOUENCE Of. - tf.+tiwa fbt rwdtr- ~ . _ . !)iwa r~tt l.ut (c ?ART U_ OTMER SIGN~F~CANT CONDIi~pNS Cowdiliowr rowtribrti~s to drarb br~ ~ot rdsltl !o t~rr~ pr~~ i~ pirt I l~/ AUTO/ST If 1fE5 trt?e ~wdiwst [o~~idtrlrl - I Ye~ er eo iw e~tr?,e;,~iss ~.x~i eJ d~ub - Probable ulmona em h sema ~90. no ,ob. ACC~DENi, SU~C~ JE, HOMiC~DE,~ D~TE OF INIURY HOUR MOW INN1l1l OtNRRED IFattr r~trrt ej i~j~r~ i~ pn! I or rrtrf !I, itts 1B) OR U~+DETElMi?+EO ISptriJ~/ I.tlo~tb, U~y, Ytarl 700. 20b. ~Oc. 30d. INIURY AT WORK ?IACE OF IN1UR~ Af bnwt, /arw, slrttt, /~tfOry, IOCATION (Sf?ftf O? N.1'.U. i0.. tif~ Of aj(/~jf~ itrrt, lip/ lSpari/7 l~r or wo! a//+cr blds., tlt. /SDrri/7I , " ?Oe. 201. ~ _ CERi1f1Ut10N- .Ho~fb U~~ Ymr .Nowtb Uq Yto AND LAST SAW NtM/HfR 1 010/D1D NO) DEAiM OCWR~EO Af ~bt )/wcr or ~ /HYSICIAN: I AUVE ON ViEW iME WD~ (NOi1l) Ibe d~te, rwd fo ,~,a~j_~ ~ AITENDEO TME TO ~ A1o~/b D~~ Ytsr AfiER OEAiM. ~bt be~f wy ; ~kwou•/id~1. drr f~ ~ 2/0. OECEASEO fROM 21b. .~tc_ Ztd. 11~. - M. tb~ trrt~(i) il~ttJ, I - CfRJIf~CAiION-CORONER: Un fbt br~is oJ tht tsrAiw~ti~w Ilorr o/ dtrlb Tbt ltttJtMt u~f pr~worwriJ /erJ ; , nl rbt bndj aud/or !br iNrnliaatio~, is w~ np:wios, dra~b .tlow/b U~~ Yre~ 1loars ~ nic~rrsd o~ tbt d~It ~sd drt to ~bt ~~riNil if~ttd. . ~ 7Jo. M.. CERT~NfR-NAME lf~p~ or priw~/ SiGt+AiWE ' Ut~~n.rliHt OATE SIGNED ~~o. S. R, Gerber M C ron r ? e.-~ ~3~. 8 31 70 MAItING ADDRESS-CF~i1f1ER STREEt OR R. .D. NO. Cft~ O~ YIIIAGE STAiE ZI~ ?)A. BUR~AI, CREMATION DA~E NAME OF CEMETERY OR CREMAt RY LOCAi10N (l.il~, vill~~t, w rorwl~~ ISt4i) l.?prril ~ ~ _ 710. ~ b. ~ ~ ~ 2~c. ~ ~4d. . - NAh~E OF-EM6AlMER IIIC. N0.) fUHEi EC7 'S SIGNATU E ~ ~ (UC. NO.) 2s. vbe~lt ;L .iJcJu G~i~i-R zb. • 1~f1 ~ONE AL fIRM ANO /DORESS, (STREET NO.) (Cil 1 ~STATE~ (Z~~) ~27.-+ /Lf~~.L ~JWL f'U/LP1LC:.C 'tV`tl/ l(/1RC'l l .C. ' ~I~ _ r ~,t,a uh~.o 4~i1 OA1E~R '~{Y' ~EGISiRAR'S SIGNATUtE OA E?E li I55 EO SiGNAiUR F1SQN ISStt G/E~AIIT p1ST. NO, ? E 3 78:• 0 4~ ~ 30. ' 3t. ~ i , j . . : 'r f . ; "i~-- _ . .~t-~ , . -f LEb A~t~ FECy~~~DED - - . c~ 1~i9rebp ~:erti.p t..a., this is a true and ezact copJ i~,IUC+E ~GUMTr f~A. ~ _ 1 ~~0..•~~~ .a`~~ ~'IAT•4 ~0~.•'[~..*p l W1.F~."~ oC ~ ~ • RUrif . : :~~T~w~ ~ * + ;t_ o • led in ~hi4 oPPi,ca. Ctf~~ (:u~t CO~~ i'~ ~a v ~Ea~C pFr..:t~~ 'i ` t. 4 , ~ ` ~ C~~~ ~ Na~ 11 . s~ aN '11~ . . - - ~ ~ ~ v ~ ~x~:_~f~„~~ 9/J~G 242613 , eo~K 2D8 P~c~1521 "r • e `~5.6" ~ . d' ; ~ -3, ' ~ "'+'w F~''~ -~~~~,pu~~~~~ ~ ~ tk : ~~+c _ . . . . ~_-v~.~.~~ ~ -:3 ~.c .T ~n`..'