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HomeMy WebLinkAbout2128 243064 ~t ' ~u-EGIBLE ~R ) nted for ~ecard ~ P~ D~ OHI~ DEPAR`l'MEMT ~F HE ; rH K`R' DIVISION OF VITAL STATIS ~o. ; 1'~i~nary R~~R. I~ist. Xu._ N~~q~+u~r's No., CFR71F=+.CATE OF L~~F.~° DECEASED-NAME 1~~~~ ?G.(.~r~ l~,i SEX ~ DATE OF DEATFi ~-~~~~wt~, Un, )~+•I . CLYDE A, t•1HI7t~EY , t•tAl E^;,. NOYEt~16ER 24, I911 RACE u'ti;rr, N~C~7, J~RitI1aJM AGE- 1•~.r u`+DER 1 YEA~~U':0!R ~ ~ar D4iF Of c~~ rl.. 1).~~, COUNTY OF DEATH ti ~~r.rn/~- .{lot. 1).+i~ 1lovrt .1frw. 1'~~ ~ :~`~AUCA~I~~'ti~( ;a~$~ ~ SL ~ S~. 16. h~T. . .8~t3~ ~a. CUYANOGA - CITr, VIIIAGE, OR IOCAl10N Of OF~iH IKStDf CI/Y UM11S HOSPiiat OR OMER it:STi iU :A~Nf 11! ~ie! i+r tilGr~, air~ ftrtrt .+aJ rrw~btrl f]pe rt or N•.I ROCKY RIVER Y~~ i,, 125C~1 HILL' '~LVD. SlAii OF 6~RiM ~ll uot ia L.5..1., a~1rr CIIiIEN Cf ~VHA1 fOiJN7tY ~+•a:~.i'~ t+f.E = vaRi;EJ •v~v~?:G SPOUSE 11~ ai~a. Rii~ iw+idr» w.++rN ` s~~'l~~IIO 9. l1SA j;~~~l~~f~l`~'D`EO ETHEL M. Pi00RE SQCtAI SE:UCiTY ItJ.vEfR wtS CL.E~~'_^ ~sR ,N U. 5. ..:.v:D FC~- - q ^ /la,...~.. r/:~~ic uu1 ~ll iu.~+~ruJ„ ,:irr) ','~~~_~at RFSIDENCE 17~ `7~~0~~~~')Z ~ i~V : ~~KEASEU ~SUAt OCCUFATtON t(.ur tin.t o! e: .rt d•+Nr duriuK n%••;t oi KIND Of ESS OR INDUSTtC t: 'G i' C~AiH . . oN c~vf ~ S~/,l.~<'s.a;`t LAi~~3 ELECTRI C L/1[30PJ~TQRY i3D. ~"~u•,E 6EFOiE qES~OEr+CE-STaiE COUNT~ C~TY, VittnGE OR IOCA~tCN INS+Of t riSlSTREEI AND NUMEER ~`i.QY. ,.,?"~;~IOtfIO ~ ~~C~JY.1t?~GA FQi.Y,1F RI~'ER ~~rrYE ~ ~.~1II501 HILIIARD BL!?D. fAiNER-NAMi I iut til~u.:lc L.:ft ~~rGi»' f- A/aIDEN !r4 f ns! .~I~N.lit i..ul ~ ' ~ 4'IILII`u•1 E, tdNITI~lEY ~ .R11 DIFtG't~~l y i s. _ ~ (NFORMAN7-NAME ~ wA1i~hG woe+~_:S •.U. r~.. c.r~ or ~i:1.,a~. ,rJrr, e.pi „a t~iRS. CLYDE A. '~'HITt1EY . 1^5~~1 1{ILLTA:u ROCKY ~I1'E~ C~!T~? •^•='•1?6 t- - . , ' rwe~ DEATH WAS CAUSED BY: F'JicR CNlY Cftf C~•:St f°~ Ut1E F~^,i . AND !di r~J~ ~ CET~vE:~+ OhSfi n ~ CcATH _ ~e. ~ - ` ~ 1 ~ i IMMEOiATE CAUSE lol / . • - 1 ~ - - ' ' - OUE TC, OR AS A LONSEQUE?:CE OF• ~ CONt!lIIOAf. JI VR). ~ . vLirb F.r:a iift r. ` It) - im~erdi.dt r.~r~re ~.+l. - _ if?!iK[ f:~t «a.itr. J ~~E ip. CR a5 A C015:Ji:c~:~f ^ !)inF :.IUtt :Aft ` ~ 1 MRi ~I. Oi?:ER StGN:NCwNT COND+T70r+Si.~,+rJit~..Ni .outrib+.rirei ro Je.+rb but u•.t r~~.~ltJ tu •d41~ rittw ' I l~IIAUlOPSY IF Y~S u.~t l.v:'~.r. _...r.d ~)'tf ai ~od »v .l.A•n:rnr,rr a ~ .,•I. - ' lOO. ' 19b~ ACC~DENT, SU~CtOE, Y.O.~~C~Df, ~~.TE OF tc+;UQY HOuR ~hOW tN~URt OCCURi +t~r N.lIMt( O~ ~MjY~I IN ~.1~( I•.r ~...t IL i~: OR ~Jt~DETER+t.NED ~Jpeur~l r.11-.•r:i•. ll.+r. ]-t.:rl - ~p, ,.i .ci. _ T y INIURY AT WORK •IACE Of INIURY .1~ !~•.n:~, l~rm, tfnrt. ~.ratort.) iOCATfO`1 IStrer. I'.D- qO.. [iti Or tilidSt. tl.+tt. ah~ _ ~~yt.~~~ )u ~.r x•i! ~•.!~•as ot.i[.. rtt. !~j•au/)/ i i - c~:ii!CpitOr.- .llout:r U~t 1 e.rr' ~D.u1L 1 r..~ ; AvL• ;=_T S~~h' M~~•. ~t"c2 :'9Y~wl1 ~ DEa7M C~:u+KE~ .1: .~r _ ~ PHfS~C!Ar~ `AIIVE ON w iNE BODYIIMOUR) tl•e•.u:r. t~ . : At7EnD'cII iMf TO i ~!c'--,'. l~.~~ ~ . ?>Tfy_ { +r. ' ' / / I % ) ' ~'tl'It~:fa~;P. .:Yt ~ 2:0. CECEASED F=OM ~ - , . I714. • ; T 1 ~ Z~c. - ~ . ,-1 ~ ?le. ~ M. t:it.:K:<•:i ~t~t._L C°_'.hF:UT:Cti-~O?O'~fV (h~ ti.i ~.~ic ~i~!%•r:a.:n:n~,lf~•.v ~l-it/r o~ ~:a.:tb 1 hi .iaatl~r. u~. rdJt~J ol tl•t b~~.1i JU~J~ 01 II)! lN1 (fIfCJIl017. !!J pil nj•~.riou. ut~~er ~Liut..+ Ya.+s HDar ....r..,~J ~.r rl*~.i.rrr Jrd :Lr.~ io rb~ i.+usr~tl u.+ted. \ : : - i7o. M. liD. CERi1FlEt-N~vE ~ l~ipt or p.in1/ ~ SIGNATURE / :ut or fi!!r . OATE SiGNf~ ,~DR~ HE~aRY Ft P.OE'~IGv ~ r,~ . . - ; r . . , _ - - ~ ' ~ Ml,IUNG ADD¢ESS--CER7aPIF4 S?i:ET CR R.F.O. ~0. 'JTr : R . _ STATE Z~F ~~a3 9 nf. ! ,~c ~~rr , rF, ' 6URUL. Ci.F.Mni~C'.' t%AiE '~~ME OF C~~•EIFR~ G£ ~~:w.Tp?t ~:Oi:.t'C ~iil.~gr. or iur.ctil ' rJ1~ •r~ti~ } - ~ •I D 11CD j ; ,.e~URI~iI !~.D1I 27 71 2.~.LAKEt~tT~'JD PRRK C~"FTEP.Y +-=a P.~ I._... ONIO_. - NAME OF EtitBALMER - . (UC~. !+OJ {FUNEYAI L:RfCTOR~S S~C~,N. - , ~ (ltC.~t ffr ! . ~s. THO~~:IIS R. EBQEA.T ~ ` ~.~61b$_~ ~ ~6. . - r . . ~ 4872 + I FUNE[A1 RRM AND AD~RESS ~SiREET NO.1 ~ - ~ IGTY) (SiAiE~ (Zlry SAXTO~~-KL~(iKE_EU:;EP~flLHO~'~ '~Y3~15 8gTR0IT AVE~:UE, LA }OD, ONIO 44207 ~ . - OATE REC'D BY ~REG~S1R~pS S,G~AIURE ' ~AATE PEq~~T I5~ ,ED S.G`iATo PERS~`4 (SSU~N' PFR.Wi ~ ~ D!ST. •:O. IOC~I N7'~. I ! ~~f / A / 1 ~ ~ / - ~7 f , +,-r tI ~a. ~ r::~~'7I ~ ~ 'G~/ I s ae.. 3, ~ • _C-c ~i..__ T ~ . • r .1 V f ~ y L . ~ ' • a .1._1~`~~~~ ' 'v ~ P~t m c~ ~ ~ ~ 1~ .i~ ~f 70' C C ~ ~C Ad ^ r. n: s :L~2 i~ =i.-~C~~ "~CtUGx ~ ~~~~=n b~ p > = C y'*O ~ a r R v ~ So~c2~$ 243064 ~ ~ ` f ~ II~€~~~~~ = ~ ; ~ - . -