HomeMy WebLinkAbout0714 MAf~YIAND STATE DEPARTMEN? Of NEALTH ~
~ IV ION OF VITAI RECORDS, 301 W. PRESION STREET, BAITIMORE, MARYLAND 21Z01 ~ A 2 V~ ~
1819 ~ ~~6~3 CERTIFICATE Of DEATH - • ~ ~ ~ ~
:;~iA~tDKAMf frsl M~ddM losl ?o.DAlfOF0EAIN jbllplR Q
<<, v~:.:1 r' _ ~ c.. ww+* 3 oor'7 / r.« ~ P ~..a~ ~ O
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i t r-- n t R
A( E ,~~~f S. DA1E OF IN ~ AGE (M r~~ nu r eae M rn z
Ef~1AL~ r~?X~J'vXX:;l~rl,7lITE (c% r~ i~~ ~~~ra. •0~e ~ ~
= c,11nP1J1(E (Stole^ 14 Ct112fN Of WHAT (OU!(IRIR t lAAtitIED Q NEVER MAQit1E0~ COIMIr OF DEATN ,
{'l G~ S /`T 1MOOYYfO OIYOR(ED ~ ~ll A / / ~ • ~ D ~ yd, f ~
. c:l Y OG lOX7i OF OEA?N 11. NAIIE OF FIOSPITAI OQ 1115i1TUilONf11 not in lasptd 1ia USUAI O((UPATI011(Kaid of ~a4 da~ 12b KII~ pf WpNfii pR ~
, ~ yne st~eN o4dras) 3•2 Y f~d r~c r?1 duu t 1 w k~ng !t~ rtn it utred ) w~
1 ~11 ' ~
i~AI.TIriAR€-- ~•,-r- Ld,1c ET'~'~~1~E~ - Al'D H06PITAL
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JAl RFSIOEN(E (M1~liere dtteoseA ~r , a~roAtN~on Rts~dea~ btlow 13t. Clilf OR TOYYN ul wvDt tm tr:~ 13a SlRffi AN~ NUTABE it ~ -
s~,~, S,~TE ,yd ~ t~ . ~o a ~ k ~ _ ' ~
.
fA1r.ERS NAMF Fint 16dd~ last 15. MOTNfRS NR~DEN Y•AME First M~dd4 lost Q• ~ A;
, E ELLC ESTHER ~ ?
VvAS OE(EASfD EYER qi US ~ltYED fOR(ES? I6p.50(Ul SE(URtilf N0. 17. NiFORMM'T Ilddnss ~ i
tes, r~. a wiknorw) ' h ms~•••bw.t.«.rtd SRS. tA t"" :
~ DELORES JESS 4401 ALAN DRI~IE #21227 m~;
GUSE OF DEATM (EMa a~lp ar caru pa Iw~ ,o~, ro~e l~i) i • wo ~ '
PART L DfATH WAS (o) ~ ~ ~ ~ D
I o~ io, a~s ~ canEa~ a ~ ~,,a,~ ,
~c r:d~?~ons, if am, which gove (,Q~ O
~ u ~o ~mmediotr ieuse (o~ ~ 0' OR AS A [OfISEWEtKE Of G _ _ . - 0 ~ ' Q
c!crny tM uadertying couu C~
~;er ~e) T ~ a"
~~RI 1 OTHER SIGMIFI(Atll (01~1T10l1S CONTR18Ui1NG i0 DfAiH 6UT NOi REUTED TO THE TEtMtNAI OISEIISE OR(Wm1T10N GIYEN W PART 1(0) - f~'' ~ a~
~ ~ ' ~ ~ x ~
~
s: oai E a oPtr~?twN i~ to~ata~ fort wn~ oe~~u?taw wns ~~u ~oo. wtoPm ~ae. ~ r~s, r+t~ Fu~ou~ ~ ctat~rw6 ~-a p a
uus~s a oe?T~ • ~ _ - ~
- ra ? ra - . ~ . - . ~ `'7 ~C
~ w uN ~ ~ i~~. tu?~ aF uutRr 71c NOW IIiIURr OC(URRED ~E~r« ~w~ o~ .~.~r n ran i w vnn , n«. iy . ~ «~~~G
.i ~ x caa~wr+,. pcwst a oum NOUR Arl Month Dor Y.or ~ . ~'i
_ ;'t ertner. • enedicd ~xonw~et) - ?JL lf ~ ra
d t?!;JQY OC(UfiRED 21R PlA(F Of INNIRY ~o~mu~iuio
C. F~twn.l tlf. l0(AT10N Stseel or tEO. Mo • ariewn-- ~Gmry J StaM 4.~ C"~ a
~,"-.,ie ~ Ilolwkk~ ~ -
.t n~~rt 011YGk . . si= = - ~ 1~
tla. I certify that (Q (this hospitul) atten~d the deceased from 19 to - i91L; that we).bst A~
sew the dzceosed alive o 19~ ond thot in my ou?jopinion~eoth aaried on the date ondlrB~Te tM•' ~ y -O C
causes stated above, (I) (didj (did not) view tfie body oher death. - - - - - ~ ~ r ~ h
i1b 5'GNAIURE n . 21c. OAIE SIGNED -~i y A
1 ~l_~~~ - ~z. -3-7/
~ ~-~'-C~ . DEGREE p
~ ~ ' T1IREZT~I~~flt~' ~ ~ ~ ~
2ij PhYSK1A!!T v j ^
NAw.E R1rP~1 ~ ~ l~'R- V 11 [,~.lh l~-~ u ~ `4- ~ _ .`~rv 2.-r~-= ' _ ~ ~ O ~ `i'1
_ o":;Ai. (REAIAllOl~, ?3b. OAiE 73c MAME OF (EMETfRIf OR CREMAi0R1 ~3d. LOCATION (Gtr or To.~nl (~"h) ~d~) O y . a
~~,`1~i~~ 12-5-71 t'ASES t•t0?`7TIFIORE BALTII~~P.E, t~fARYLAND
' Fu~ERAt DI~E(IOR ADOEESS 250_ REC'D 6~ RfGKi1GR ZSb. t~ RAR'S SIGNANRE ' D
~ ;GL LEVINSOr~1 ~ BP.OS. ~6010 REISTERSTOitilv ROAD ~ ~~7 Gl~;.iY,,yr~ _
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