HomeMy WebLinkAbout0064 . ~e~~.-~~i STATE OF WISCONSIN ~ ~
; • , pEPARTMENT a ISiON OF HEAI~IAI SERVICES 249914 53
~ou?~ f~~E Nu~R . CERTIFICATE OF DEATH
OECfASEO-NMAE fiM Mi~dl~ lat SEX DATE Of 0[AIH Mon1A pey Ywr
S i ne w .
RACE-MfAi1e. MltfitMJedipyEk Y~las1 ~iAl~ ~ p„~ Yeor IMde~ On~ Go1l ~t~llTH ~^tA 0~ rea ~p~N1Y pi pEATN
w tso~~h~ s~- 6~ se. ~ 1 s~. ~M s. March 18~1908 ~a •Sa er
NAME Oi CIIY. YIUAGE (If
NtitlKr, Na~~ TormiAiO) t~tidf City K NOS?ITAI OR OiHER INSi1TUT10N-IWAE ~A
(locolien ~f peoW ' Ylioye Witi (II Not N EitAe~ Giv~ Sue~1 end ?tun+0er M locotan) •
~rh ?N H ~morial Hospital
S?ATE OF ~IRTN UTIZEN d YMhat Country SURVIVING S?OUSE
(II NOt i11 U.S.A.,Nos~ CMmlry) n M~et Nb~ritd (lf Wit~, Givt MoidM NorM)
Norwa 9. US ~o. o w~~ o o~~a Hans Halvorsen
SOCIAL SECI1~ITr N0. USUAI OCCUPATION Givt Kind o( YYOrk putiny Abst of Wwkiiy Life KINO Of {USINESS OR IN01{STlY
Even U Rdind
12. _ _ I~e. 1Jl.
RESIOENCE: STAiE COUNTY NAME OF CITY, YIIIAGE lesidt Cih N ~I AppRESS (Hame Addrets ot rn~ f peotA)
c't T°w"'"p~ v'"°9' ~'"„n 1~2~ Causeway B~vc~ S. 337'07
Florida Pinneles St. Petersbur .a.~ Y« o~a ,k.
FATIIER-NMAE finl BAiddle _lest MOTHER-IYWDEN NAME Finl
~s. Anders Thorsen ~a Anderine Jenen
~ INfORaAANT-NAME MAIUtlG ADDRE35 Streel x R.F.D. Ib. Ciry a Villoqe Stote 2ip WAS pE(EASEO EVER IN U.S. AllMEO fORCES3
170. 17b. er y~ O~~nef StnKt)
1L ?ART 1 OfATN 1NA5 UWSEO !Y - Enfa Only Ont Couse Per Line Fa lN. (!L aW (Q burg, Florida 7 7 1bProiienat~ IMervot
~e Onset and D~WA
c«a~~~. ~r M,,, ~ c~.: ~`"once
, whicA Gore R~se a Oue % a as o -
M laned'ah Couse (l~ b. CoeseauerKe ef: -
~ StWiny f6e WWea
3 Lyiny Caru lost. Out fo. a m o ~
~
~ fART 11 OTNER SIGNIFICANT CWiG1T10NS: Coeditions Contrieuterg Io Deoth but not Rtlotld fo Ceuse /WTOISY (Specifp) WERE fINGINGi CONSIDEREC IN
Gi~en in ?ert 1 W • . 1~ Q ra ~ No ~ WVAINIO YU~USE Q Ib
~
0 ACCIDENT DATE -0F Month Dor Yeor Hour HpW INJURY OCCURREO (Eater Notwe e( In'ryry in ?ort 1 a Porf 11. Item Iq
~ Q SUICIDE INIURY ~ ~
~p 200. ? MWNICIDE ~0e, ' p~ ~pd,
V INJURY AT MIORK PIACE OF INJURY (Hant, farm, Strett, Foclory, Efc.) IOCATiON Strat or R.F.C. Np. Gf~r x Ydloge Sfoh ZiP
< ~ Q Ya Q Ilo
CERTIi1GT10M-MonM por Yeet th Dor Tear IVip LAST SAW HtM/NER ALIVE ON DIO YOU YIEW THE pEATM OCCUR~EO Af The Plocq on The
~SICIAN ' MontA Oor lfsor ~OOt AFTER OEAiN (Hour) Oote, ond. To The le:t
~Deoio~sie
F~
w T~ ~ ra p po fi : 4 5~M o~ c~0i"arset'
s`
i
si
~`ce.
- Ib. 21t 210. ~le. All
p CERT+fICAT10N-N{EOICAL EXAMINER OR CORONER: On The Cosis ef TAe HOUR OF DEATM THE OECEDENT WAS PRONOUNCEO DFAD
E:awaotion of Tbe todr ~d/x The ImresYqotion. In My Opiniun, peoth
~ Ouvmd on ibe De1e and Due To TAe ~ousels) AWed. . MonM pey Year Mart
~ r~. 6:45 PM M. ne. 9~ 29 72 7:OOPrui.
~ CERTIf1ER-NMAE (T~rpe a Print) SIGNATURE-CERTIFIER TifM OATE SIGNEO MoeM Ooti Yeor
Wx~. Albert J. Bloom x~. Albert J. Bloom-De .Coro 10-2-72
MAIUNG ADDRESS-CERTIFIER Strcef or RF.0. No. CMr et Ylloye • Stofe Iio
' r Wis . 54843
WRIAt CEMETERY OR CREJIItATORY-NMAE TION Cih Stote
i Q CRENUITION
F 410.0 ~~K ZIp. Winter Cemeter z,~, - Winter, WISCOI1S1I1 ~
~ < WRIAL-OATE MIseM Dor Y~or FUNEIGL NOME _ a90 ADORESS Street x R.f.D. No. tih x v.~~oge Sfo1~ j'~ .
~ z~a. t ?s.- _:.~iderson Funeral Home Ha ard Wis. 54843
~ FIIMERAI OIRECTOR-SIGNATURE REGISTRAR-SIWiATURE DATE RfCElYEO ~y lecel Reo:strot
o~, r•o.
sss. Robert A. Anderson Laura C. MeLa an ~ Oct. 3,1972
.
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~ - ~ CLE~~r . f T,,eS ~T_~~
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OFFICE OF REGiSTER OF DEEDS ) ~ Ol 249914 :
55.
Sawyer County, Wiuons~n (
I, Laura C. McLaggan, Register of Deeds in and for said Couity and State, do hereby certify that I have mmpared fhe
foregoing copy ot ~ath_Certificate s
~
with copy of original now of record in my office and find the s~me to be a true and corred transcript therefrom and of the -
~
whole thereof. I further certify that said original was retorded in my office on the day of _~t~er_
2s00 P
A.D., 19_?2, in Volume - °f ------DB ~t?~i ~p~_-~- ~ pa9e -53 at oclodc ----M.
~~T ~~~s _P~....
O + ~ : .
s' J ~i
~ 'L-• •"~i ?~.r'- .
In Testimony whereof, I have hereunto set ryy~,~tand ,r s e• ~ ~
5 , . •
.
S lI ~ ' `~r~,jr.~=-- ~
and offiaal seal, this 1~ ____._~a~,of~r•:';'" URA C MdAGGAN •
; ~A.~, . Q, ~.~_kq ,
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--------------J~------ A.D.,~ i3i'~~. ,~~bf'beeds, Sawyer County, wsconsin .
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