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HomeMy WebLinkAbout2918 CQNNECTICUZ' STATE DEPARTMENT OF HEAI.TN NO ~ Public He~lth Stati~ties Sectioa-Ha?tford~ CO~plC~ICYI U.S.A. ~ 2'~396 ~ v Certificate of Death 2~146 r.~ F~ ai.oo P:•cc or Dr..?tu: (a) Stat(elt~sceticut 2. Vsu~~ Rc~os~+cso~ D~cs~~se: fal S1ate~i0~• ~tl Cn~nty ~ (D) CeYStf (e) 1M?w ~ - . Id) ia Re~idel~~ln~wtc ~'C~N/ t 1~fl~ PH /Vp I`llf~V1PH I ~ _ ti• , Clqr. ~ BaouR? Limita! ~t~ ~a,n~ of itoepiu~ o tiwtwn (e1 8treis N~~ber . Yes. No ~ • not in ~ 1w~Diu1 or instiWtioa ~ire Steret Ka Nf ranl, tiw bcation) •.c-,-~~',' . ,`'U Yer. n~me Citr or if «'itatiOA~ ~~p~- S cs ~ae~ s /~osp ~eed s ~s'a p , ~ ~ . Nor=tk~~.Branford ~ ;::.MC w ~tt~~.ci ~ Q ~Niddk) , i. Se~ctw4 SpcyNtY XVKwt :~tit~iLO _ J~,^ ' = L_ . f!7Dt O~ ?ripl) Jw YI.~ MEDiCAV 71FICATION (T~ ,t pERSONAL AND STATiSTtCAL PARTIC C~use w DurN (Eete~ s~b. ~L~• ~„~u~~ re ~410; t.tt?f •eece~ l. .Si; ~ BAC~ Z. ~ARR[tO p~ 1'1i~it KARRIW ~i~ 4r V~~~~ ~ lNTtlr'AL pr ? YA~T 1. DCATN MA! CAU/1~ ~ BT ~~w~N ~~j/L° v~A/6 V° w~oowss ~ 1~~o~cw ~ irrsotwts C~VSt 3 - ~ ` ONSiT AIiD ~ OiATN :s ?Iwant0. Wtoowso oa Dtro~cs0. ctR ~lwtosN NwNS o? i•pAqe . ~ ~ • r?~n oa H~a~~tro GZ E~eQh O{~ Co n n e//~ b~~`~ • D~is 0I cDlostL) cDar) earl ~ D~~T~~ Coaaition~. ~~~~iqaclarosis 1 be~e.~ ~~j ~3 ~91r Z If an~, rrhk6 , D~rc o? B:etu Acc (in rern if under I year if under 1 da~ ~ t'O abo~ve c~we la~t birtLdq) xoatM ~ Da~ Hwn ~ Miw. (a). statin~ te~ esderb- Dus to !e) G!3o/•i9/o ~2 1 i. 81~TM1LACC lCitr or townl (SUte or foreisn eountq) Nortti aya•,~ord CO PwRr il OTNii $If.Nl/il'ANT CONMTN+NS CONTIU~VTIItG 2AV o sY /7 n• TO DCAtH ~Vt N07 RLI.At~O 70 TNi Ttt7l1MAL DIR~1 CONOITI~N GIRN Q~ PARi 1(~1. PCtrORIttDT . :2. b) Usv.?~ OcCVrwssor (Gi~c kind o! ~ork done durins most o[ Yd Ho ~ workia` lite even iI ~ ? ~ fCy? ~~V G !'~'dI ///'td • it. Su~cu~Y Rsufwxt ro Coaanox~ Itsroatso IssK Zt. (6) InousiaT ot Bustv u~ N~eae ot oper~tioa - I(b) Date per[ermad . _f . ' T}_ (a) ~Yws DiCEAS[D A VLTERAN~ Ycs or No ?~s (b) 1'iML M 1NJl'RY ' r~'(bl It Te~. Yir~ war- ~p 1! KO/'~Ll. 2i. (al AtttosNT Sutaos Hon~ctos ~ K~r _ XewtA. Ds~. Yea? ~ ` Uoit or ShiD II J N$~ ~ . . ~ a o o ( ~ ~ It. N~xE ~IQ[~~D14 IAIi I~ /QI~f S (el IN~uRY Occuaarn ~dl PL~fi O? INJV~T (~.y.. iw w abert A~..~, ~ (Cny or ..o) (5t~te or tbrei~q eouatql K'hile st Tiot While 1~'*~. 1~t~rY. ~trs~t. ~~it~ 8f1/.. ~ta) , ~ ~ N ork at Work ~ - ~s. H~.T~~.~.,,~ A/orfli ~t~_~,.~_ C1: 0 ~ + MAtD[N MQfie n ~I'/ ~6 S ~!I CtTr. TOMM. OR I.OCASION COUNTY STAT[ ~ i :i. Nwwt (Citr or to+.n1 tStat~ or torei~n eountryl ` , f y 1:. IIl~TI1Pf.ACL ~eL~~jQis ? /t/ DESCRCSC How INJURT OttU~tio. (~OhI1. IEwter w~tw.t eI iwir?y i~ Ps?t ! ~ :L Iniwx~„i s Nwus w P~.t 11 eJ it~w !t.) • E /'7~' S /I/Q/r)s ~ ~iR~I ~,r 2t. I HEREBY CERTIFY. t6R [ ~ectewded~thrd«eercd7~0eR ~ 5 ~ ~ ~ ~ ~ ~ lp ~ Ttp~. _ ~ ~ ~ Ig~ ' ~ E 1!. Bvtu6. Cttilw7lsrreR'~teuwwL Dste_ 19~ L~tY.lt~cd.toC- -~•~t nrern~?enr~.~aa;.~.---------:s--- . : c~,~«.,. A ; Ylace ~O~'f. ~O/'c~ ~01> /f 111~that deatU is NW le h~~e oteurnd o F~ ~ • ~ i0. YwY-~ 01 EKfALMEt tI AS Eri AL/ILO L~Ct11if pW11bli • ~ ~ ! _ ~t t.- m.~ ; n ~l~ A~~ KI /39Y Z~. S~~N~~~~~. ox,rie .E,~~my. ; :7. Sscti~~ j~ x c u• i s . i V:.`~ „`l l ~ : ! ; ~ -r~s~~--~~ + ` ~ ~ ~~}'~L/ ~ , • ! Addr~~ = AdJrtss ~.J~~ `'~~'~^Da4 W^` F ?Sl~ CERTt ?E ~ EIV~Y. RECOSD ON Rtusr • ~ • . ~ D~em~~r. Z~, 1962. , s. R- . - . . _ . cf;i:3S VS-4 ` " _ ~ i "`~~'r„~~~ . ; ~ 1 ccrtify tbat tbi• is a frus tras~t~i~t,of,tbe ' format n oa t e de~ reeo d as recorded ia t~is o~ee, ' - _ ~ ~i~ast:' ~ ? DACA~~6~'.,;.,~~ ~g63 Reti~trar oF Vita1 t~~tics a DY<<d ..................u....T..~~T.............~....... • , ' ~~~OS • c ...........TOMA of Ha..Y.r.~.,.................. . , : ' NOT GOOD WITHOU't SEAL OF CERTIF1fING OFFICIAI. ~~.~x~ ~tCOltQe~"""" t r,,.~, v.s. zsc ST.LUCIE CLUNTY FIA. • ROCCa POI7RAS ~ - ~ CIERK C~~:CUIT COURT ' , RECOP.D YER~F~EO.~._..~.~. ~ ~IIL 3 I 35 PN'~ 0 Q ~ o,.~ : eooK 215 2~~1 s 3 } , ~ ~ . _ ; ~ > ~-3