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Home My WebLink About1572 25pg93 ° - . : : ~ c 1~1 ~fificate af Deafh . 5~,. F~ " ~ STA?E OF IDAHO R`' HIRINNO ' Rcq Onf.No.__ t. DIACE OG DEA~N - USUAI RE510ENCE iw~r.~e~c~~sai,wa n..m.we.on rwe~eeNa~~+.w~ 1 a COUNiY ~ ~1~ a. STATE Fl rid b. COt1NTV Sarasota ~ 7~'- bCI1VORiOWN~~to,.n,a~co.oo.a~e cIENGTHOF A.CITYORTpWN1~~wn+wcaoaw~~+~ni.wnwwunwtMa~w+.wwo~ ,owwy~0) STAV I~w aa W~cM Sand oin one da Sarasota d FUIt MM~~E OF ~i~ ro~ ~'w+u,a a r+u~eui~on yr~ suae~ ~ed.m o. bcaowl d. STREET ApORESS I~~.y.r. wcarow~ HOSPITAIOR Box 1418 ~ ~ ~ ~NSTITUjION 3 hA~AE OF DECEASED •nu e. IM.O01~1 c. It~ul . DATE I~wl ~0.~1 ~rwl John ~ - Jacob St 1 DEATHAu ust 5 1971 S SEx f, COLOR OH RACE 7. MAHp1E0. NEVEH MARRtED, g. DATE OP BIRTIi 9. AGE u~rsrs UNOER 1 YN. IF UNDER NNqS ' WI D, 1V0 CED ~so.c.?ti~ y,~ ~ ~„N„ ~ p~s w.n ~+u+. Male White ~arr~e~ Dec. 5 1910~ ~ b'~"` IOa.VSUALOCCUPATIONIGwe~.~,eo~+.o.~oa+e IOb.KINDOPBU$INESSOR » BIRiHPLACE~suuo.~ere r~ 1?.CITI~ENOfYYMAT a,.rp Ton or ww~ Me. aoen ~r rn+eo~ INDUSTRV yw cwn~. Business~xecutive Plastic Manuf. Chica Illinois CO1f'~.`~:A. 17 fAfHER'SNAME BIRTHPLACE 11_NpTHERSYAIDENNAME BIRTHPIACE John _Stum f Austrfa ~.ena Sortmer - Austria ~S W0.S OECEASEO EvER ~N U.S AHMEO FORCEY 16 SOCIAI SECURIiY NO. 17. iNFORMlJVT'SO'V47i SIGNATURE ' C~Oil1ESS ~ vK. ro w un`wo+.e~ ul rw f~ wa. a. exn o~ wvi~i • ~sy~~ No ' 318-01-7267 ~»~L Illinois ~ iR CAUSE O~ UEaTH MEDi CERTIE •..ATIQIII ~ ^ INTERW~lETYYEEN . Enenc-:~onrcw.row~w 1 DISE:~SEi/RCONUIT~ON / ONSETwNODEATH ~o. ,w ~ /"w /Y, R OIRECTLVLEAOINGTODEATN'Is1 ~ /tf~'~Io ~ 9e . _~~l/LS, I FILEU AFs; RFC3ROE0 'I 'TAn does rot mto ANTECEOENT CAU$ES ' ~ r/x .ma4 M Ay:ng. such a ~+o. n.e ~o~.a~w.y rtir. OV E TO Ibl T. U v'.~ L' k 7 Y F A p A nea.t/an.rr. arMenu. e7t. ~ T~^9 ~w a ~ne ~o.eca~+r .fi'.~iC:'. ~•'•i 1 ~~S ~ ~ ~r orrs d.e o.xae. ~~Y','~'~'"'' °^°^'r~+ CLEF.K ~'~Ut7 COURt ~ , vv /ury. or comp/~tahm - pUET~lcl ~ •n OTHERSIGNtfiCANTCONDIT10N5 l: on.f.t~ons conn~p.t~y oo ~ne Oepn W t rot . ~ .e~s~en to Me e,+eae o- cd~d.tm can.A deM~. A^~ ~ ~ 0~ f{, ' ur w ~ t9~ DATE OF OPERATiON 19h NAJOR FINDINGSOF OPERATIQN ' p~ 1(1. AUTOPSY~ - ~ - - - - ~ vs lJ N~ ~ ?'a ACCIOENT ~sve~~~r~ 210.VlACEOFINJURVIas.iwwaaa~t Z1CICITV,TOMM,ORTpy1M$HIP? (~UNTY) ,.~~ISTATEI ~ 5UIC~DE ~ ~ ~ ~ nun~eann.~~~wb.stn~t.otfsWe~.wcl ~ ~ ~ r~ry,ttClpE : id 7~S!E ~vwtn~ +D~v~ ~res~ ~Mw.~ 21e. INJURY OCCURREO 21t. HOW DIO INJURY OCCUR~ OF ~ ~ ~ ~ ~1tlE f1~T NOT MNIIE ~ ~ ~ ~ ~ ~ INJURV . m~ A YqRKt_JATNONK ~ ~7 ~ n ~ e.r. ~~trnakr~ rne ~kreased Irwn_. i9~~ ro , t9_ _ . ria~ / bsr saw d,e d~ereasrdar..e S o ~ 9,~ . t dta~A occurzed it m,/rom At ca~aes yW on M~t tple w~ed~ppre ~ S~GN T E ~o w er ~ u~~ Y3D. AODRE55 ?3c E SI NED ~~Ct . 'z~~ n/,2~I . ~ /0 1s Fl~At C~EtiMaTiON. ?a:. AtE ?4. NAME Of CEMETERV ORCRE1rtATORV 2fA. ~pCATtON ~e.n.~owao.<own~ ~s~xe~ ~ . VAl doeN 1 i Remova'~ ! Au ust 6 197 ntrose Cemeter Chica o Illinois ATE REC'DBV LOCAL REG ! RE AR'SSIGNATURE . ~ 25. EriBALMER UCENSE NO. ~ 3 ' Dale G. Cofflet E-501 ~ ~ r+rs n~qr~cr F~RM N~ME Coffel t Funeral Servi ce ~ _rseat5tne.~..re~ r~eaK~Sanu FORM ON 6]O11 ~ _ . . ~ - . ~ _ State of-- Id~t?o. ) COt;(1~~/~.~,~c7~~;3 - y . . . ~ I ~ ~r~~a`S . _ . l:': ~ ~,~`I~r~~ _ • Y• That this is a certified copy of a certificate filed ~ .~wi t~,~at~':A~ pa irtment of Health under Title 39, Idaho Code. ~ ~ ' , ~ - ~ ~ ~U-:~:~, ?`:'-'.+~r.:~. i ' ••Ln, " ~,j/V:~ * .,>,`~w~r-` • • ~ ' tii,j+7•. ~~`~J' ~ 1i1... ~ ~ Dat~ °I~~d State Registrar of Vital Statistics ~ ~ . . . . . $ooK 212 .PacE 1572 . : , _ ~+.w.,...~.. . - - - - ~ ~ . x= ~ ~ ~ v ~r~ _