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HomeMy WebLinkAbout0602 , , _ / , . , . ~ . . ' 25459'7 ~ ' ' ~ . - . ~ ; cEarFlCn~ oR o~?TM ' vs~a 1`n OONN. sT~re oEar. oF ~T?+ ~ OEGEJ?SED-MAYE yeoaa w* ~ { Farl Charles Shafer ~ male a?tE a swn~ «o.~K e... ..w. MCE -.~..c re«a .+s.w wtiE - w. ••w woa. , w. a?lE of oEl?rN ..o..K e... .w~ , June 26 1896 . whit~e" .ttov. 6 1972 WUliftt-OF Ofwn1 ?OwN OF OEATN N06rITK p1 OTl~A w31tt{R~ON- ww ~~a . etir[q Mr! s~~sr ~e r~rRlr , l~ew London ;lew London kLawrence tc ~~emorial Hospital ' cm a sr~.E oF eam~ ~c...~r. ~~w us~ anz~ oF ~a~.wr~ uuw~o. ~rtn ~o. rnooMreo. u?sr ~ nr.+r. N...wr.w~ Franklin, Conr~. USA .°NO~ma'rr `ec~~""~° ,~Gussie Perry ~ _ ..K~[ au.xo a~v[o n a.r~ SOGAL SEWroT1 MweE11 1lSW?L OCCt1rATWN ~arc oro or wo~c oo~c aww ros~ v ttND OF WS~NES3 OR MDIlSTi11l ~ 0l+5 10 0129 et{ red Carpenter Self - Building ~b«~ wdrssww RES~OENCE-STATE COUIRI/ - 70WN STNEET AND M~1lEII . Con:~. ilew London Groton ~.381 Cow Hill Rd. liystic w~s oece~o ~ v~¢n~t ~ ves. mve w~n u~ar o~ sw~ ~vcan .cs aw ~w ~ n ^ N. ~ FATNER-NAME htlT rOQE LAff YOTNER-MAIDEN 11AME HMf Mpp~[ u~n „ C'~arles Shafer I•lary Binley INFONYANT-NAYE W1RMIfi AODNESS IsTKa dl RIY. u0. dnf On iwM. tf~R a~l ,'•;rs. Gussie Shafer ~ 3Sl Cow :?ilI ~d. I:ystic, Conn. 06355 P~wr i. oewrn wns c~usFO er: IENrEn aur o~ CntuE rEn u~ son W. ln). u~o k)' ~o.~r.?c .~n..K K+.ca own u.o otwm ~wcourc cwx " . a ~ 1'V- `('.L.~L ~ ~Ll.~~ I . S ~ 4? earana.s. .s u.. ~.w a,c ro. o~ ws ~ corscoucuu or GtrS[ wN4 Si•n~0 M ~y ~`r"L ' . ~ !-~q S C!~'~n~y ~ ~ ~ . 1M0(Alt~MO flYSE lA!* ' T ~ ~ OYE TO. WI b A C01~1[OYfMCE O~. ' /~n r ~ 7 p " `~LLV ~yi ~ t~ 'y`V ri ~ :J ~ C3~'Y '7 •S ~ ~~a f ~=;?A `IT I NSTRUCTIONS ?MT 11. OTMER S~GMFICAMT CONOfTrONS' CO~O~ corTwwnw To oum «n ror ~awm ~o ewat ~new ~ r~un ~/wrOrsY s rES ~~c r~ow~s oo~sot~ee ~ °~D CAREFULL~ ~ n~. r ocTCwr wrx or oun~ 01 G,K ~.~c,~ ~t4rr~:c ~sv f: i ~(~'-~tt:,a~ltr. ~'r' ~-v cb i t~•.~rc l a S ,w ~ ACC~OENT. SU1C10E. 1~OMMJOE. DATE OF INJU~I/ Mo~*M. w~. ru~b 1101Jq NdW bilUNY OCGlRRED ~+rp riu~t Or ru+~r MLM11 AT rf011K NT LEGIBLY with a on unoerew+~!~o n.~an~ rue ~ o~ ?~uo w, ~m ~w ~s.Ean.o o~ ra B'ack RecOrd Ink. a. s. s.. ; COMPLETED, t~1~3 ~~E ~ tWUq1r ~t wor[, rur. sr~ctt. IOCATION pr~tn o~ wr.o. ro. an o~ To~ sr~~q St11KiEA1l REIEYANT TO CaND1i10N IId011TFD M rtEY 1~ ~ r.cTai.. wnu waa. ac rs.cam nr....r.w+w~ rar r.~r..w ~ ^~ou!d be sent to the t • Ot v~tdl 52alIS1iCS 111 CERT~FICATIOM-YX~ISIGUN: rprn~ y~• .u~ ro.,r„ y~~ vu~ w~o usr s~~ wrc aw OEwTM OCC~IwED or nK wrE, ~rq ro nrt ! here death occurred. ~ ..,F«o~o..K r / b ~OiM ~"r tMO~E"~ 017~ ~ i•. o[c[~sEO r~w ~Vi 'Q~6~ *otN. ~ J v ~ i~~ l~e. ~v ~ ~ f/~ tti. j~~ Y. 10 M CMAEI~ ft~r[Q ~ ~ CERT~ttCAT10N - ME0IGAL E7GMINER' w r~ Ory~wO~. OM nrt O~tE ~r0 ~M Os O[~n~ nrt OECEOEw? w~f MOMOUrtlO OG~o ~ 0.~[ ~O TN( C/1~y[IS/ S/ATEO. O[AM n1EiVliED OM M A~Wf YOM1M O~~ tEM MOII~ n• r. l tt~ r ~ CE~~c~ER-nAUE n.~[ a~ ~~m S~Gt+ATUqE o[o~[t ow mu o < ~ ~ . : l L.~ ~ r~ nr s ~ ~ n,~~ r~ a (~,i :~.1. ~ l~t • ~ ~~C~.u~us ~i.~c~,. ; ~ J ' p~ N~ ~ MAIUNCs ADDRESS-CERTlFIER sr~n a~ ~ro. ro. an w row Si~tE WTE SIGNEO MOM1~l a~. r[v0 O I ( ~t y ' ~ i~ r 0 ~ !k G ~'C• L~~ fVJ~ IU ~_y~L O C~ S 7 ~ ~W~ ~ I'{ l Z S1 ~ r aw 9tJHUl. CREVAT~ON. RE40VA 1 CEMETERY OR CREMATORY-NAME IOCAT1pN an a~ rpr s*•*E ! t i. O r ~ w ~ ~:i[ur~ ( y~~~~~ 7.. 3:^~~:1 ~~lr.! G„ove ~eraetery I~iystlc Conn. ~ _ OATE na.•~. w. .cwM FuNERAI NO~E -~u?wE AND ADORF59 rs*~[[* w¦ r o wo. an a~ Taw. s*~*c nn °'>~cres ~ I ~ LL~°`~~ t, :~ov. 1°72 I n~`.~urc!~ Al' ~n ~nc. 17 Pearl St. I•iys*ic, Conh.06355 ~ Vf 4 ~ L DrpECTOR EY ER-SKiNAT NAME OF.El~IBALMEq n~om w[rwrto UGEI~ISE MWSfR ~ ~ -~?.~'.a'i'OTqw9 Le •^1'1^r 1j29 ~ f' TNIS CEATFICATE RECENEO fOR 11ECOR0 ON BV ~`~y ~.=X: 1 HE iRAR ~ • ~f 1Q~c ~ ati. ~~•f~ - GQI t~~' f~~ . . ~ << , ~ v~I ~ ~ II I eertif7r tbat thi• i• s true tran~eript ef t6e~-i tioa on tL~,a~a~ reeofd a~ reeo?d~d !a tbt~ effie~. ~ .Z~C~~.: ~ . ~ a~t R~si trar of Vi~al Sact.a~. ' ' . = . : ~ Atte~tt ..~G~~ .~Y t t ~ ~~~ya.,~.~ i ~}~/~7~y~ /+*t~/~r~/~?~ , ~~ted • t_r ~4?t>x3 f?TLtd 1?"!.!,!~1l.N.i.Y.Ok'lAl11rs11.A.~M.K.1.... ' ~ .~.~Y TeMS ef. ....».4~t:n... E~rm V,S. 16 (~-71) SSi NOT G~O~D WiTHOVT SEAL OF CERTIFYING OFFICI/?!. ~~Ry r`~`- ~ V ~ . ~ 1 {~4 Jl ' ~ ` " " _ " . . . . ' y:,'.. + ~ ~ ~ 3 r fi'+A A ~ ~~.3 ,;8}' 2 y~+r.~ _ . - s~ . ~ . . ,'..~w'=. ~Ta~. - '#o?-~'S . . . _.t Y .~"~i~'`' '~',R~ l~