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Ara 25 t za PM'73
r J-180 ~ CERTIFICATE OF DEATH
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p[CEASED-rtAME r~n~ •~wu u~~ OATE Of OEw111 ~••o~+r. nu ~
, MAY LAVEROCK ~ female ~ 3-14-1973
RACE ~e. Neow. ~reuuw ~wwr. AGE-us~ Mee~ ~ w wee. oA/E Of ~1RIN ~ raw~, wa. COUNI~ aF OEATM
, nc. ~venr.~ W~ilt@ ~ ~.n w~~ .~r.. 11-24-1894 .
jackson
~ pFj~ .~~e an ~rw~ NOSI11nl OR Oll1~ MS - ~r ua w~ ewiae, aw swen u~ wrM ~
Jackson ,y" yes ~ Jackson County Medical Care Facility
sTw~ of Mem ~¦«o• M.w utae~ of ww?t oou+nr ~o. ~va w~e~c. su~vN~+ci s'a~ ~..w. aw .Mrs. ww ~
L,.~,,,,K, ~ Michigan °°w"" , U. S. A, p°O1ME°~n owe~"~" Edwin (deceased)
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i~rte r MuM SOCU?l SECU~ MM~ER USUAI OOCINA?10N ~Ont uw O~ .+ou e0n! oMM6 r0~~ p K!O Of MK~ESS OR RO{K1~1I
«i~ ~ ,~384-Q3-7677 `~"ho sev~int~e a t home
~ ~ESiDH+CE-sr~1E tour+rr tTf, ViLU1CaE OR TONIMSHIP ~sn~ ra w s -
,N Michigan Jackson 14 jackson e3 ~ 1027 S. Jackson St.
/AT1ER-NAME ~af~ rMq . Wt - MOiMER-MADEN NAME NMt rwM~ uw
George Smith Nellie Phillips
~w~o.MM,r-?+~u~E w?a.+c? ~oo~EU ~ar.. w...,. no., cw. w w.~.. a.., s.i
~k Mrs. Mary Vandenburg 1027 S. Jackson St. Jackson, Mlchigan
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~A~T O R SIGN1fICANT CON0IIIONS: carnws wwa ~o ear ~a No~ ~u.o a uvse oneN r~ rur ~aaK~ i tES ~n w~M~s coM-
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IHIURY AT WORR MACE Of NJIR~ wo~.e. ~u.. s~tr. r~oo~*, IOCAi10N ~ snea o~ u.~_ No.. an o~ rwrr. a~e ~
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CEti1FICATION- ' N~ nu roNM wt rw uo ufr Mw Mr/~ Knt oM 1 MO/M MM ~I!'~ Mt 0lAM OCCYM~O ~t w~! rut~. or wt
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~ T10~i- ExAMINER OR = o.~ ~e wn a a~ ~ a w. ~we ~ea~?n .u wawwcw ~w
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N~1M OQY~l1 ON M~ Mq ~M~ ~M q~M UYltW fiqR~.
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wwu, a~u?na+. ~Mo~?wi o~ a~v?rar,r-?~ iouna+ an, viiu~, 1vw. oR oo~x~rir ...+e
burial Woodland Cemetery Jac icson, Michigan
r,~ 3- l~i-~11'73~ ~~The
We
her~iy 402 nVl~~~dWOO~ Ave
~ jac~~on, Michigan 49201
B~~ iWNAI D~K7OR-SK•MAiU~E REGIS h~ W?R ~[CEnEO IOCAI ~E6KitA~
8-~ tZ : t, i~l 7N.
300M 2M.
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County of .,Ja~J~sori_ ~ I, RICHARD D. HITT, Clerk of the County of Jackson,
Stat~g v~~I~}i~a~B'~ I~iichigan, and of the Circuit Court thereof , the same
. r.,,.....,,.. being a C.,.,rt of Record having a seal, do hereby
F`= ~~rj'~.. certify that I have compared the above copy of the
~ ::x~ -
(S~eal) r'- RECORD OF DEATH with the original in t~e custody of
.a.i:
• o'_ my office, that the same is a correct transcript
~~~FI TE ,0}? `D~ ' therefrom. and of the ahole of such orig ina l.
c~ + 1 ~ 4+-;~.;~.~r - : ~ w .
j'"' ~ IN TESTIMONY. T~iHEREOF, I have hereunto set my hand j
~f'~~( ~~x~,. .'c and affixed the Seal of said Court, at the City of #
- y L ~ ~i~, . .
_ ~ ~ ~ " . Jackson, on this date: ~ 1 ~ t973
. _
_l~}~A$i) ' D Hr~R~~ ~
Ja~dc~. '
dHt', CE~~k~ ' ~
Jacksq~ l~ic,~, igan : puty County Clerk.
. . ~ g~K 213 P~ i339
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