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HomeMy WebLinkAbout0662 ? t i' a / 9 ~ ~ ^.C.OcPL CF Pit6l.'~.: :liH ~ i ~ ~'ll'~!.! R~!;O1?L', C:IYlSION 2S46~4 w'-- ~ Yezd D:aTRICt OF COLUMBU DEPIIATMEII? OY PIISLIC H~ALTH ~litc ~~~z oE;; i~ ~e ~~3 ~?~~A~ oF D~,?~ 72 09449 y Bi.rN ~a r.s xw . ~ ; 1. ~J11fS O? DZCiAiID Fint Afiddls Iw~t !a. DATS afMtA Dsy ~'M. ~~b. Raa o1 JOHN A LUX D~?'~December 11 1972 ~ 2: SS ~ pf ~ SEX QOIAR OR RACS S. \ever M~rried. AATS OF H1RTIi T. AOB (Iw~~~ ~ ~ Wd°~ed' • ~ ° bo,~a b. yy~/J L~- l~t.i> c ~ 6/~ ippu~' s. PLACS OF DSATB IN WathLl~Qtol4 D. C. f. U9UAL RS81DEIdC6 (IiAen l~tMNi liosi. Il iwrtitrtiow. swiJart is~w AiAI~iS OF H08PITAL. NUIISIN(i AO)!8 OR 01'HER IN877TUTION a BTATS / A b. OOUl1TY ~ / (11 ~et i~ i..ritrtio.. ~iss u.ea ~1.tN) ~ ~ ~1 e. e. ~IN~FY YES O~ a b~ P - ~ i!!• 3'f d. STRIIsT ADDRSSB (/J rrrd. I~ loe~tirw) ~ ~r' 3800 RESERV IR RD NW ~ 1~ IC' uL-6- N S ~ , ~ ~ t p~ blaek ~e;,, , i'3UA1. OCY'~7pATlO~i (Cia~ kiai oJ rork dose lOb. KIND OF BUS1NIh't8 OR 11. BIRTHPLACB ti CI1'lZI~N OY~HAT d0U?ll'RY duiwD w~wt oJ / nrd) INDU3TRY (dt~te or J ~ow1~') ~ "f~" ~"v p s V~ -s ` 17a. F~THEH'S NA2~1S I~b. MO'IAEIt'S ]dAIDB~T YAJdS It NA~[8 OF BUAVIiriN~ BYOUSS u~ N w~~ G ~ q ~v n~ ~ wG ~ a~p o c- ~v w, l- u Icaie be- ~S. E~er ia U. S. 1{. BpCIAL SECURITY DiO. I7~. 1NFORMANT RSL~!/U\SHIP TO DS BASBD tJb. ADDR838 &mt C3t7 Btat~ ~ OY1RfIII1eAY •~+mnl FoiresT ll ~ ~ _.t!!,-~ t S A~3 ? v~ Zd whan 18. CAQSi OT DtlllSs (B~ed o~ty owe carae ~er tiws /o? (b). ~wd ~ Intenr~l Bet~es ?cstuitd. ~'A8T I. DSATH WA8 CAU3ED BY: ~ aod Ik~th: ; I1dMEDIA'1`E CACSE f~) m ~,j`~ ~ ~ 4 Cundifio~a. il aY. ~ r4~ ~i1i~~ ~ ~ • rJ~ich garc ri~e to DUE 1~U (b) , ~ aboct ~awe (n). ~tsf- I submi2 a ~ isy ehe wderty~wo cswe : of Dealh ' ~"u• ~ - 1 ~ tparfinenf ~ DU6 TO (e : Heal3h H pAR'C IL OTHER 31UPiIFICANT OOJ7DITIOrS: eontributiu~ to de+t6 but aot 1fa. AU1'OPSY1 lfb. ItYes,i{'ereFiodinp ' f ~i refated W tbe te~wio~l di~eafe co+~ditioo siree in prt l(a) Yffi OR NO u DMamini~ Gure oI Da f :hours af- V /V Q,.~ :S a~:v- ~ IF ~YERA:'fOY N.~~ ~ERFOR~iBD lNM. DATE OF OPERATION 11b. C~ONtDITIO~i FOR R'AICH OPERA7'ION y~. ~ fhe laWS ~ CO\1PLETE IT£]i' f0a~od 70b I-,L v`Ais FERFOli~lED ~,~yGa,ti~,~ • isirici of W ~ : V 21a. ~iM~cify if ac~W.nt, wici~le, homi- tib. HOCR A\D D.?7'E OF INJ(•RY: ~oatb, Day, Yea~ fle. DESCRIBE HOW 1NlURY OIX7qRRSD ~ a :~de. or wanner uMetmniued M (Bwfd watr~ve oJ /wjrry iw Avt 1 or flrt I j ~ , V ttd. IUI'RY AT WORKc 21e. PI.ACE OF Iv]URY: (dt Nowe, Punw, F.cio.y, !1L I.OCA170v CITY OOUNTY STATE : c ; (SpeciJy 1'u or No) Stnet or O~ce Brildiwy, EfcJ :R w . . I!_7~., b-- 1~.~ Z. O?at W(w~i Im? { ~UT 22_ I e~r~f! that p) bwyllaA mNnd~d d~~d tros ---1~-`---r~---- - j2- ~_r ~ CHIS saw tb~ d~e~m~d ali~~ oe If yt~ . med dat d~a~ oeear»d iro~ oaow~ asd oa tw dab ~d lo~r stabd aLsn~ y f~r-/1--------• ITAL" 22a. SIGNATURE , ' ~ tlb. DA1'E 81(3N8D t G AT'I'E\DI~C \1EDICAL STTAFF PHYS_ llIRF.CPOR PttY3_ L~I L~~ of 2hese ~ ~a;;E ~ y.''~,~~ Michael H Safavian MD ~ 3800 Re~ervoix Rd :~nishable in:pLiSOII- BI:RIAL ~ . D~T~ 2~. ~ a}E OF CE11A7~R1 OR CRE~iA1'ORl Xkl. I.OCATIO\ (Cit~. to~ew. or ~orwf~) (&stt) S CREAt AT10~1 xEatovwc. ~S= - 7 :1~ L ~ r~C ; ~u.-~ ti r"-' hn ~ir2S Va ~ 2~. FL'\ER.?L tIO~lF. _ t ~77 ~1i't" ~"~-/V ~ ~ 23~. ~\D TAKER'8 $IG TURE . [iNDSATAHER'~l ; o ~,C~ Ri'sGISTRA s)!V * .~I~DRE~S ` .c+ N 4~ V~~? ~ _ ~ • : . -:-.:___r hUMBTsR /4 / p ~ ~r .r-~ , ~~~~r_ r I ~ l + _ t REJfARKS: ~ ZtCORUE~ • ~ ~.ts ~ 'w"~+`~~ _ : 3 ST_ LUGIC ~d - i _ • ~ . ~ , - ' _.1;-,.:..~ : 15M R~:,E~ ; 7`T CS ~ ,~~'~•~~y~. t ~ ar ..V T OUR1 ~ „ : p,E~nqi; r= : • • ' ~ ' : i' a:~ , Mp, ~7 _ ?l~ g,r • •yets; 'Yj • ~.;4:.: - _ _ r ~ , ~.:nt',~'fi; l;,'~,- ~J.,' i ; . . - s - ~ ' . - - - . O /1: ; : ~ ~ . . . { December 29~ 19?2 ;r. " ~3 Date lssued: ~ ~ ' '1~F~THOUT RAISED SEAI t -a . : ' .t.: f . ~ THIS tS TO CERTIFY TNAT THE A60VE IS A TRUE AND CORRECT REPRODUCTION OF ~ _ THE ORIGINAL CERTIFICATE FILED !N ORUER WlTH THE VITAL RECORDS SECTION ~ ~;r;~ OF TNE DEPARTMENT OF HlJMAN RESOtlRCES, GOVERNMENT Of TNE D i STR ICT Of COL- s : tJMB IA. , . Soor. ~.~4 ~~~~c U~ , V~ ~ _ T_~ F ~ ~ ; _ _ ~ ~ ~ ._l~-~l~lII~~_ ~ ~~~sy~~.~.~~''~~-+~'~'T~'~e~ ~r 4~- Y` 3 . .~s4°'? ~ "`Tr h , " ~ v j _