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HomeMy WebLinkAbout0375 - - - - . - - h ~ ~ c.~~ ~ NEM YORK STATE eo ~~no~ . ¦aco~sau o~~T~~e? ~Cn~~~,y OEPARTMENT OF MEAI.TH • 1422 ~~t~ ~ BUREAU OF VITAL RECORCS ceNSUS r~s. ~ CERTIFICATE OF OEATM ~RA.CT Wr1310N At{I~T[AMYM~[¦ ~ 12 TYPE ALL ENTRIES OR PRINT IN PEfi~AANENT BLACK INK. 1. NAM[: FIRlT MIDOI.[ LAiT 2. !tt ~A. O~?t OI O[An~ MOYR MA~t ItMAI[ MOMTM OAr ?[Aw tT~T1~TICAi OI~tMCT / ~ O 1 O~ ~I 'M• ~i[C. 1. 11At~: I~RNIt~. Nl~AO. A~[ _ 1? VI~OtII 1•11. 11 YMO[A 1 OA. •A. r[1t11AM O/ U.S. AI1M[O ?OAC[~1 1/ ~~tCiry wAA~ ~A AMIwICM INOIAN. <Tt.l YOIItNl, OAY! MOY11~ 1 MIN. 1 OATt~ O/ ~tA111~t ~ ~ •t• MO YMtNOM11 ~ R~,. 73 : ~ o ~ o ~ . 0 M 7A. COYNTr INYSI 17~. fOw11 ~ 7C. CIf~ 011 YILIA~[ ~ 7O. ItNSTN O~lTAr IM ~7t. MOS?IT~I OA OTM[A IM~~17Y~IOM t 1 I 1*OMM~ CITt Ow YIILAe[, II~ M[ITM<A~ ~IYC lTA~tT • p0.1 4. r ~ ~ ~ ~ v ~ ' ~ r 1 / Y ~ ~ S. ~•.lTAT[ Or ~IATM Ott[OCMT ~011M 10. C~TI2[11 O/ MMAf 11. MAAItAI 1T~TY• 1s. WAYIrIM~ NOY~[ ~I/ MI/t~ YAIOtII IIAM~I ICOYMTAY.IIMOTY• MOMTN OAt ?[AA COYNTwtt • ~ 1 ~ ~ ~ 1 E. t w. vsu occu~wt~ow tcvu ~tt~~so1 ~ tss. x~wo or ws~MC~s e~ ~weus~er 'tst. a~c~wt •itv~~n w~. 1?. 1 _ ~ :su~~ ~ts~otrtc wN[~[ ee ~ t ~ Q '~7 + ~[C[~~[O 11Yt0. 1• 11A. ~T~T[ 1t~. COYMTr 1~C. TOMM . 11~. tlft OA Yltl [ IIE. wITMIM TN[ ~ 141~. fT~[t~ NIO MVY~[A 7i~TM OCCU1111[O IN t I I COII~OAA~[ LIMIT~1 ~ ' L/7 MsnTU~iow. s~vc ~ss~. ~ ~ ' 7 ~e~cc •no~c wo~+~s~~ow. ~ ~ ~ ~ ; •u wo i ~ ~ ~ Q~ O ~ • ts~, r~?n~c~•s Mu~i: t~s. wo~ca•s ww~orr rurc: ~ n~sr Mioo~c •wsr s~wsr ruoo~c ~wir r ~ ~ ~ ATTQlTION 1~A. IM/OIIMAIIT'{ MAM~: '1~0. MAILIMt wCOAts~: IIMCLYO[ ZI~ COO[I . IYV ~ ~ ?V [~11011 If MOt[O Ir, A ~ ~ . ~ [~TI/lCAt[~~IOA[ACC[~• ~ ' • / ' ; cw:[ ~r ~t~~~~RM A COb . ~ LCT[D Ct11fN~tATtYAr - . JeftITUT[O. Y~IIOt1YAT[ IMT[AYAL ~ PART 1. o~Atw Mrws CwuftO [r~[~ oN~r Or[ C~ua[ ~c~ ~~M[ ?o~ IAI, l~l. Iw0 /CI. ~[~wtp OM~[T ! O[~TM i . aM .IqCOA11[CT CtAT111• 17. IYY[OIA AVf( • ~ ` •Tf MA• ~[tll ACC~*T[0 r TNi R[{I~TAIIA. /ll[ IAI 7Rtw V,f, Oyt TO A! A CONS[QY[MC O ~ CONYITIOMf. ~I ANr. MMICM r _ (L (/n ~ iAV[ M![ TO IIJMtOIAT[ le) 4 ~G~/Kr~ ~'G44 ~ CYI![ (A1 lTATINi TM[ pyt TO OII AS A COMS[OY t O~ ~ YMO[AI~INi CAYl~ LAlT ~ ~ lC1 dj t Z PwwT t~_ orMC~ s~sw~ncu~r cOwanors: towo~TwMS coMT~~wnrsito 1~A. ~11~O~s~1 •s. ~?res.wc~s nso~MSS cows~ouco pi<Q Q~ O[ATM ~Vr 110? w[LAT[O TO CAYS[ i~rp IM ~MT 1 1A1 ~ •[f. MO ' O[T[IIYIMIM{ ?N[ CAY~[ O~ OC~TNT V Z • ~ I a MO a 17. °z'"~•-~.~l. O 1 : cC~p M I~A. ACCIO[MT, NOMICIO[. 100. MONTM OAr ?~A11 1~C• IIOY¦ ~~D. MOM OIO 1MNAr OCGYIIT IpT[11 MATVII[ O~ 1M/YA1[f IM a17 1, OA 11.1 gt~1~~ y-~ ~ fYICIOt. VNO[Tt11MIM[O ' =~~-r.[ ~ 1 1 1 i 9A. O-VjO~~ I~E. INlYII~ AT A01111/ IYF. /IAC~ 0/ IpJVAt: MOM[. • /~C. LOCATIOM 1lTA[~1 \ MO.. CI~~ 011 YtllAi[. TOw11. COYMTr. lTATII ~~~~,,i~ N r^ts wo t iwcTOar. o?r~tc ~~es.. srt. 1 ~ ~~+J. J ' ~ u ? 1 ~ ~ ~ TO BE COMPLETEO BY -0R_ TO BE ~OMPLETED BY ~ ~ _ 20. PART 1 CERTIFYING PHYSIpAN OlILY 2o pART 11 ~~ER OR MEOICAL EXAMINER ONLY ~ ~ A.TO TM[ •[iT 0/ V~ Rr l~Oi[, O[ATN OCCVAA[D AT A. OM ~M[ ~Afl~ 0/ «AMIII~TIOA MO/011 IMY[fTItAT19A. IM M~ ?M[ ~1M[, O~« AMO AC p OY MOM M OAt •CA/{ O~~MION O[ATN OCCYI~A[O AT TNi TIY~. OA~[ NIO ~LACt ANO ~ [ •T~T[O ~ • 1^ OYt TO 1N[ CAY![~ lT~~tO. y • / • ~ / ~ I, ~ ,~TL~ 1 ~'~-?''',~.1. . _ 4~ . ~1....... s~aMCO._ ~ y~ 0 TNf ?M~lICI~M ATT[MOtO•fMt•Ott[~![O C. lAlr ![CN ALIYt B. •1101~OYMC[O O[~O C. NOYA O. O~T[ lliN(O ` ~ r`rt~y ~ / MOMT OAt [AA MOMTM OA~ ~[A~I MOMTN DA1/ •[AO MpITM OAr •~A11 MOMfN OA~ ?[AR ~t 1 Y I/~1 ~ i~ 1 ~ ~ ~ ~ ~ ~ . /ROY: ~ f I TO: S • ~I ~~i ON ~ AT M. ~ ~ ,~\t v~3 r1 p~O1M~ ~M~lICIAM• 1/ 01 NAM 1/ - E. COAOI~[11'~ ~NtfIC1AN. 1? OtM[II tNAM C[~1TIIItA: t, - ~ ~r . . ~ ~<< ~ _ ~ : G-.-~Z, . _~Y~~ ' ° 2t. ~wYfOOA[/! O? t[IITIII[ I~w~s~u~w. coRO w ~t~~ t ce. t rsiti~w. r~toit~t m~tt `,•.aQ?4;~" , 6 /l~ _ ~-cc.~L..c.~.-.~.~ i . ~ _ ~it R~Y~tt~'~f. ;~i~~ . • -.:_i~~ O~ 22A: ~Y11111t t11tMAt10M IItYOVK MOM711 OAt 11[M 210. KAtt O? Ww1Al. CAWAf10R OA IIW011AL 22C. IOi~TIOq (Clft OR ~A. ~TAft/ ~ ..~/s•~ 4 / ' ~ • ~ ? ? ~ ~ / , ~ . 21A. ~~rtt uio ~oo~c~~ o? nrwcaw~ Now~ ~s~~~T~wfiew • s ~ . = `n'-' ' ' /y0 ' D ~L ~'!r S~ ~ t < ~ AS' ~ ' ; i~A. N~w~ O~ ?rw~~wL O~~ttTO~ 1 AfYA[ ~I IVIItwK ~IA<CTOA '=~G. At~1~fw~T10U MO. ' ~ ~06/ ! ts . ~~MA,u s~~* ~R~ ~ • s~A. K~A ~c~ ~~srt~ t~~ Mew~w ~Ar •s~ul ~ /l~f . II~[~ 1 ~ ~?i • ' ~ • / ~ ~A7[ • (L:iJ~'lJG........ i EC~OK °ACE ~ M