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HomeMy WebLinkAbout1300 ~ . , ; ~~093 OH10 DEPARTMEiIT OF HEALTH ~ Re6. Diu. No. ~ V Snu 64 ' ~ ' ~G`,l DIVISION OF VITAL STATISTIGS ~~~~~,4 , ~ p"°"" R`s. n~`. CERTIFtCATE OF DEATH ~ ~ . , DEGEASED-NAME F:nt .~4ddle I~st SEX D~T.EQ:~ ~ J~i;%Y~+ J~~1~Yf4~ ~I o o ELLSGIORTH ~ - f~ ' FQAN IS `cA ~ RACE R'bite, rrsr~, ~~nit+~ AGE- LuJ U?iDEt 1 rEA! UNDEt 1 OAY DA~E Of NRTM (M~rt~, Dr~. 1'1 ~ ir.ti~~. etr. ISI~ri111 ~i.~bd+ rrrtl ~ef. Dqi Horri Afir. Y~+~1 - / WHITE s,. ~i~i' se. s~. s. JUI~'L 25 1925 - UT~, VICIAGE, OR IOCATION Of OfATH INSIDE Utt l~M1iS NOS?ITAt Ot OiMER INSTITYiIOt~-NAME (I/ r~1 ir f~ii.~ ~ ~ e~d rr~inl fS~t~i n or s~) ~~-1 ~b. CANTON ~'~S ~e. DOA- TII~IICEN HERCY HOSPITAL " ' STATE Of ~I~TM flf wN i~ U.S.A., r~Mt CIi1ZEN OF WHAt CWNTlY WRt1EO, NEVEt MAR~~ED, SURYIVING S/OUSE (IJ~riI~ 1~~~ nrrfr~l WIDOWED, GIVORCEO IS>tcilll ~ - OHIO 9_ U. S. A. ~o. ZLEMAN ~ SOCUI SECUtITr N11~4ER WAS DECEASEO EYEt IN U. S. AtMfD fOR(C/EST 295-18-4051 1~b f•~~Sr r~+Fur~/OR~ W~ Il/ 7~t, ~i?s ~ra ~t Ltu strrisrl USUAI tESIDENGE 120. w ~ vinERE DECEASEG UwAI OCN/ATION lGirs 4i~! ~I uo~k doat drri~t arul o) KIND Of WSINESS Ot INOUSTlr r ltvED. IF OEATN - ' OCCUttED IN ~o~~~~ G/r, ~~~e~ ?rr~rlJ DEALER STANDARD OIL COMPA.~Y { iNSTITUTION, GIVE 17e. ~~b' ? ; QESiOENCE {EfORE lES~DENCE-SiAiE COUNTT GTY, VILIAGE OR IOCJ~TION INSIDE CIT1 IIMITi SiREET AHD NUWER E ~oµiss~a+. ~s~« a....l OHIO ,~b STARK 14t NURTH CANfON ~a 2475 BEEC~i00R DR. NW FATKER--HAAtE Fint /~ail!!t lttt MOTNER-MAIDfN HAAtE FbN Slildlt Lot ~s. pI'~y~ NEAI' (D ~s. ORPHA BANKS v INFORMANT-NAME MAIUNG ADD~ESS fSnt~t or R.F.D. r., c8~ n vill~sr, ture, u?/ - ?1RS. E[~4~IA JEAN NEAL „b. 2475 BEECHMOOR DR. NW, NORTfi CANTON, OHIO 44~ rwer DEATH WAS CAUSED BY: [ENift OHIY ONf UUSE IE[ LINE fOR (d, fil, AND (dI N~~x~~11iE INiEtYAITM ~ ~ s• . ' IMMEDIATE CAUSE ~o) AC COROrA_ Y ~`T - DUF TO, Ot AS A GOHSEOUENCE OF,+ - Cowlitie~t. iJ ~s~, + ~cbicb s~rt riir ro Ib) H ~ic~~GIQH - i~stdi~lt tirie l~1. OUE TO. O[ AS s~ ;-C.':S=QC:~CE OF: . . ~ tl~fi~s fbt r~drs- ~ - ~ z. . llisj f~rrt l.+ff (q _ _ _ L-- ~ 1 tAlT 11. OTMER SiGN~fICAdT CCNDi7tON5.~ ..~....~..uug !o d~~1L arrt wot r[Ir:td t~ c.+yu dietw is Iof AU70TSY If YES u ns /iiu:i~p [O~ti~l[rl.l ~ IYtr or se i,~ d~r~r~iRiw~ clrsr ~J J~~tb w,. h0 ivs. - ACCI~ENT, SUIGDE, NOMICIDE DATE Of INIURY MOUR HOW INIURT OCN!!ED (FJIt/ Wt?t 1~ iyW~ J~ ~I?! I M'Ifl II, if~s Il~1 Ot YNDETEWIHED lS~ttiJ)1 /1NoNb, D.q, Yt~r1 ~ - IOe. 704. 20c. ZOd. J IN1Ult A7 WORK fIACE Of ~MJURt Af bo~t. /.a~. ihttf. J~ttnl. IOCATION lShstf e? R.F.D. sif~ M ci!l~~4 A~tt. aill .1 ISkcill l~+ ~r +~l ~d~rt ilJS., ~tt. fSlrr:/71 ~ . 7~. 7W. 7 . ~ r CEti1FIGT10N- Mostb Dq Ytn .11oWb D.ry Yto wND IAST SAW HIM/NEt i DID/DID NOi DEATH OCCYRRED At tbt )lrc~tt •r INTSICIAN: AtiVE ON YIEW THE ~ODT {XOUR~ tbf d~ft, ~s~. to ~ ~ ~ t ATiENDFD TME TO Moslb Dq Yro AsTER DEATH. fbt ~~+f 1fa=j}'~~~ ~s~~rltJS~. Lt b ]te_ DECEASED FlOM 210. 71c. Zld. 21~. M. t8tt~aut(fI st~ftl. CEtT~fIUTiON--GOeONER: Oa tbt w~is e/ tbr es~aixuiow Hor. ~J dt~tb Tbt JsreltRt r~i ~ro~~r~tt/ lyd o/ fb~ ioJl i~d/er fit irru~ipties, iw sl oyiwisr, dt+tb Ate~lb Dq Yen H~rr occrirt/ o+ tbt J~ft d 1rt N Ibt rirso(i/ il~tJ. 7ze zzb. NOVE;SBER ts t97~ 3:sn ~ CEl7iflEt-NAMf IT~/~t er pri~ll " SIGHAT~UlE/ Drrre..riue OATE SIGNED no C. S. SHAHEEN , M. D. -...~"ab. ~~'7'-j~ 24•~. ~3~. hOV t 4 19 i ANIUNG ADORES~-CEAi1f/ER StiEET UR R.F.O. NO. C~7Y OR VIIIAGE SiAiE II~ ~ z~a_ STfiZFC COUbF ;tO:IER, st~ cLE~~r~rm AzTr: !3 FI C~~:TON OHIO 447~2 ? ay;i T NAME OF CE/~tEiEtr O~ ClEw~iOlT lOUt10N IC.iry, ri//~st, ~r r~~Rr~1 (St~tel O o ~ s~ ~ 2. 2/71 ~.~GREENLAW;d ME~SORIAL PARK 2.eAI'.ItON SUAL'~iIT COUNTY OHIO ' i ~0~~ = 1 E IUC. NO.I fUNEtA 1GNA (UG NO.1 j s: R S TE 4874-A ~ 3291 ~ ~ iUMERAt fIRM ANO ADO~ESS (Sit~ET t~0.), , GTt) (S~ATE) 1Il/) z - 1 SCHERMESSER FUNERA,~'.•HOME, 1446 S. MAIN ST., AKRON, OHIO 44301 ` OAtfURE EG ~7 ' lEG~S !'S SIGNATURE DAtE IfR ~i ISSYE - St U!E Of RSON 1 1 /EWIT OIST. NO. ; ~ . . . ' 3 r. -c~ O/ 97e~YP`": ~ / / ' ' ,frs~`~y r. ~Y', ~ _ _ - v..,' ,.y~ ~ ~.t.~ ~.~v~'~.. - w a» r ' _ ~ 3... - ~ ~ ~ .y _ _ ~ 'a _