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I HEkEBY C~ERTIFY THAT the forrgoing is a trve end correct copy d the cfeath record for the decedcot rwmed at •
item. l ar~d thpj~~j~~ reeo~d wos estoblished and filed in my office in accordance with the provisioras ot the 7 ~ )
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~ Illicwis~t~l" ~~re~tr to fhe e8isttolion of births, stillb+rths ond dcaths. ~J j
DATE~;, J. ~ / 97C~ SIGNED
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A~~/` - ~E']~'!'/ = , Illinois. OFFICIAL TITLE ~~AL REGISTRAP, ~ `
Tjje.oragina! reto~~ ~i{iis pcrmanerdiy filed wilh the (LUNOIS DEPART~.1ENT OF PUBUC HEAITti at
~ •-S~i~ie1~. C~~ ~~S~locol rcc~istrors atc avthorized lo n,ckc cerTification, from wpics of the orig;nal
?dsotd_~ fhe~11~? e~provide thol the cerfif~cation of a death recorcl by the De`~rt:r.enf o~ Pvblic Il~alih
oFtF1~~a~J ~ii~,ESOVqRytlerl; shal) b~ primo fucie evie~ence in all courls ueid places cf Il~c facts
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