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HomeMy WebLinkAbout0431 246005 . ~ , . .Q . s~ Rcad . D~!!'~lCT'~F COLUMHIA DEPAATMEN? OF PUBLIC HEALTH ~ ' J` - ::1i!ii:lte ~ v ` CER~TIFICATE OF DEATH i 1;_s r~ s ~ . ,t.-f??~~y ~ 68 . ~823 ~ B~na \a } iu xo. 1. N11![I O! DECEASLD F~»t JI~Adte l.a.t 2a. 1~ATR 1fo~tA !M~ 1'eu• ~ tb. Hp~r ot '~th ; IType or 14int) (?F , • ~S~Mi IIt': i::.'.': ~,t:+T,{ ,~11t~t;::T 28 1968 ~ 6s55 A.M i! ~rt Oi 111• 3. ~F X (`pI.OR OR RACE S. \~~e~ Dlntrie+l. \tn.+~ed. 1?.~TF. OF H1ItTl1 7. .~Clk (!w ycn~~ f0.^~ S}tOUld~ 1 N~1ure+1 I)i~~.~ed: Speeily la+t b~•thduy) . vwt ~ Ny~ .vrq u. 'f: E i:'IiITE ;I~~~?f~TED 11-13-1~9~> . :y suppliOd. ' a PI.~Ch OF 1?F.ATtI 1\ W85~AJlOII, D. C.. !'~l'AI. ItF:ti11~F:\('F: 11{'A~n d.rto~ed 7ic~d. )J~iw~t~t , raideMS btlw~t Q~ n \~\1F: OF HORFITAL. !~DRW\G 110~1F. OR OTHF:R I~RTITI'T10\ a. tiTATF: f y T { adwinio~) ? 1 : -r •~e C\ ~ i 11J ti41 Ifi 1lii/iiYiiuRr Y~='C 1~/f?l ndd.e:~) 1 1~~l11~12Y111~ should b! ('ITti' E IN~II~} C TY LI\l1T:' ;~C i ~.~:i ,,rr ~-I••rr,;; c~~rT•~ ' (~PF.C'IFY YF:SOR \O) FITAL I,,,. ~ L~.... ~ w r i i! e n ~ d. .;?REF~I' AULItF:~~ UJ rvr~xf, pire lwatiu~) ~ ~tz~~ ~n per. _1_ 20 YLY_:C;JTft S'PFt :ET fype b~BCIC ~t0:~. 1'~l'AI. fKY'('PATIOX /Cirr kiwd nJ ~v,rk Joee 106. ri1KD (1F I1C~1\F~R OR ll. AIFtTItPI.~('F. I2. ('IT17.t:~i OF N'HAT COC\TRl T i Junep mw! of vurA~e liJt ~~rn ~J n~l ` i\DC`TRT /~rote ur J~.~tryn ~ounlryl ~ • c~RZC ~r.~ r~::c~~~ ~ ~ ir::n 13a. FATHti R'S VA\iF. ~ I36. ~t07'11F.R:~ \fAll>E\ \A\th H. \A~1F. Ob' ~C'R\'I~'1\G ~EY1C: F. i~ L IiII.D;AN 24t1F,Y IiG•:ELL t~:A::CE`~ Iii:•tDi:.1?? *'i!i^afe bf- 1S. }'vrr in i'.R. 16. S(X'IAI.fiE l7RITT\O. lTa. I\FOR\tAtiT 1dBl..4TIIi~'SNlPTOD6C!',.1SF.p 1T1•. _~hI~RFC~ Str.rt City St~te ~ Tr't r' = F'ezmanan! ~m~rcf Fnmw! O _ FR,'12:CES GOOD i;Ii.J.~11Id WIFE ~..,IE :1~ 1'~~?U~iE C • ecGr.~ when 1@. CAIIS= OF DEAI'H: (E~rcr only ene ravx M? liet 1~ (a). 16), n ~ ~ Intrrv~l Rttwern Onxt y executed. PART 1. 1)F.~T}i ~~'AS CAC~b:D IiT: ~ , (t !.~nd Ikm~h: l~f~ft:i)IATF.CAI'Stil~)~~T1!"~ v~~ ~LX~.~r C'fc~~r.-~ ~-~_7~" ~OR/~~~IA~Il~ QRj/. ~ 1 ~ ~ vGvh qaCC n~o ta y-~ _ ' n ~ ~ ~ (ai. •tnt- Lv s' j~~ ~ ~ SubmlT A nM~rt ~au~e ~ Ui F. ?O tl.~ C~W -i~~"~ ~,(~G~ .~r~.~ . •rt9 fhc nrtdnlyinp tQUat J ~ r i :l.~ of Death ,'t, ia.r. ~s,~`-- . C . • , I . J; eparimen! ~ _ I)l'F. 7Y1 fc) ~t~-''~'~~ ~JC ~~C•cs ~ r,• ~ z 1 ~7 ~ ~ CL ~-x ~ 4.• - . o~~ ~ ; Health PAItT 11. OTH}:E{ ~iG\IFICA\T Cx)~U1770X~: contribut~ns to dcath Lut not 19n. Al'T(~PNI' 19b. It 1''s. N'~rr }iswl aC~~naiderttl T iC .~Iate+l to 1Fr tenuu~al Ji.ea<e eoaJitK~n 6~~'rn ~n p~rt 1(~) YF:.~ ~N•XI I ~n lh~t~•nu~uins ('eu+e ol Dealh' r.ours at- ~ . . . s is a vio- r 1F OPF.RATIO\ ~~'AR FkRFORJIF.D I 20n. DATt: OF OPE(tAT10\ Nh. (~\L1Tt(~~ FOIt ~~i1IC~H OYF.kATIp\ ihC ~dWS E~+ CYl\1PI.F.TE ITFV~ 20u •m1 TOb \1'AS PF:ItF'O}tVF:I) ~ i"' _ lli~f*ic! of W = V 21:~. ~~»r~i~• ~f a«idrM. Fui~id~. T~xu~- Yth. Hf1CR A\D U.~TF. OF I\JCRI": \fonth. i)ay. Y~~r "ir. h}:~C'It1BF. 2{O\~ 1\JCRti' OC('t;~it ED ~ i~ a r~d.•, o r.in.•?~ ~`~rnunni `t _ ~F.'nrir ._st=irur o/ In~ury i~ 1'ast / or !~i! /I) 'Q! 'i ' - V 31~L 1\Jl"Rl' AT ~C(~JtIC: 2t~. PI.A( F: (1p 1?-]('Rl"c Ut Nnrrt~, Fn~, f'a~twy. 2!!. IAC.~TI~1\ ('ITT Cnl"\Tl CTATF: ~t.:; Q lADtr~1.V }re o :!rret or Illi~r N~~idcr.9. t.'IC.) ~ - ' - W v i?T 22. I terKy that Q) fthis ho~pltalj,qtt~ad~d ~~ec s~d ~~y- 1~~5;.~ . 19~) L_. toC~-~~'- _ . 1! . th~t m(w~) last "?-ijil aaw th~ d~c~aaed~t'n~ on _.Cr..Ltj ~L , 18 7~ nd thnt d~ath occurr~d Irom ths eauss! nd on th~ dab and hour slat~d abo-ry. ~ T:~L„ ~ _ V - SIGNA7UAE . D.~7'E SIG\F.D ~ ~ (.L ~:~TI'F\i)1.'f: at}-~?~r.a~. .ra}~f• ~ ~ : . '~c- . r~ir~. ~~i~t}:c•1•~~~t n rt~r~. ~ dC.~g ~ ' of ihesr, r:~~ rt~i~:tc•~:~x f 2°.~. :~nut~ . x.~~tt-: ~T ~.•i (f~f= ~ 'J j • d . ~.~.i~. ~ ~p~:nishable v ~ ~ r ~1 ~ ~ 1 ~ ~.r - ' imp:ison- ~ ~ 33,. Al'RiAI. :$1.. U.\lF .^3~. ..1:.\~1t: n} ('F:~1}~:Tl:itY OR ('ftY.ST.~i)Rl" 23~t.~.(K'.1T1(1\ (I•i~•~..;~.:r/or ~ev.~•y) ~ -~ute) G ~-o!h. c~[tE:~t~Tto~ ~ ~ i . i ~zr:,,o,:.?~. / ~ ~ f 31. F'l"\F.RAI. 11~r~1l: ;%L.f~u r~ I~'~~y fL1 ' C~- '\U}:ftT.~liF:l:'S I(' .~'f('ItF: :5.1.. 1:\1)}:I:TAKF.R:~ € -L ' ~ j- ~ .~I ~ ItEGhTIL\7'10\ / t \1)DIiF:.:3 . ;.-C J jL- • s XI'Jtli}:1: i , ~ . s Itl'\t.1ItK~: ~ , I.`d - r ~ ~.r ~ THIS'~~SYy _ ~~:~.-~:r.~~~-~"2~- - I TO ~(:E12TIFY~that the above is a true and+correct ~reproduction of the original certificate filed ~ith the Vital Recorde Division ` of the nistrict of Columbia, DepP.rtment of Public Health. ~ ji, i~-" 1 - - - - . . - ~ : ~ } OC~oBF.~t 18, 1968 , ~ ~ ~ . 2 . . ~ ~ ~ L'ate as~i~`•_'~'" o n: a;; ~e ' # ~ Vitala ~ ~ ~ .iS on ~ , L~ ~ /~j i,. I,J . ~ , ; ~"Jpt~ ~ i, ~ ~ C - ' ` r~ ~ I~IOT VALID WITNOUT RAISED SEAL . a, ~ • ' ; _ - - . - . . ~ - ~ . . . - ~ ` ~ ~ ~ , ~46005 ~ ~ :<< ~ ~ ~o r'r+~ a t~ i~TAY - - _ : ~ ~*+z v ' O "civp- ~ rnGOCrn ~ 0-~-i2A t` ~ y-~O ~oox 210 P~~E 43~ _ ~N~~ ~ >o F-"i w ory~ ~ ~ ~ ~ . ~ x: ~ i 3«9s ~'~'-'~-L ~~.~N a _Y~;»c."~t~..~~-:a s . , , ' _ ' ~~-..~a' ~i'•~.'~,~f'