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HomeMy WebLinkAbout2633 _ . - _ . _ _ - - - - - - - _ _ _ - - r^ 11 1 4 • ~ v~Trl~ ~ / ' ~ ';;.DIS?RICT OF COLIIMBU DEPARTMEIiT OF LIC HEALTH ~ ~ ~64~Q~ CERTIFICATE OF D ' ~ , ~ .~i~ r. . . ~ . ' f; L; x~ 6 ~ 7 ? su?ct or Dcn~x - NAl1~ OF H06PITAL OR t wot o Awsit~ Ii~r nst ~lnw) wa~n~~,, n. c. ` ~ ~.r L . aaw 2. QSOK 1tL'SfDEMMCt Wlk.s date+atit .rd. ) uae:trtiow: Reiidswu en ~wiariow . a STATE ~ NTY a TOWN, lACA77 - ~ F".~e ~ ~ ~ ~ a ~ .`S ~Yl d. STRl~T JIDDAFSS r IS AESIDENCE INSIDE CITY LtMlt~7 RESfC~EN[~ ON A FAR1fT ' D L~cLt' -nc•.~ trFS p xo p_ lrES ~ xu p : ~ Xl•Q 3. p~~p Fn,r V~ddte L.u /1 ! D~ dlo~ell y Yew crrr~o.,.~~ ~Lc.?~-•-C~-- i~ nEA~H 7Z G ~D 3 i s e per- ~ S~ 6. COLOA OR RACE 7. runto ~f:crtt riaaw TE B _ AGE IIw~r~ v~ts~a 1~ w vKw 2~ eu al rec- ' ~ q. !wt BinAdsr) XowtAa Dsyi Xorn Miw. ~ roperly ~G~ w~oo~ru ~ Hwcss ~ D ~ / ~ - + 1 USUAL OCCUPA710N (Gice tud oJ ~rork Jowe IOb. [I W OF BUSINE$8 ! 1~ IR7HPLACE 12. CiTIZEN OF WHAT COUHTRYi ; i rr~~y Most oJ w+?Y~w~ tiJe. esa iJ rctirtd) INDU ~ : (&ofs orsi/+e cow! ) ~ ~J ~ w 1: 3 . 3a. F'/~THEA'S NAME 13b. ~R'S Al[~EN l114E ~ t~. `~M j OF ~9URVIVING SPOUS ~ /1 ~.//J M'. ~i 4_ /o-sc Y ' t_1~`.°"~<„'' ~jl .~~r .+~{:ct - !S_ W!)G DE~Et+SED EVEA M U. S, AAIAID FC~RCESt 16. Sa(.7JlL SDCURtTY NO. t~. IlfFO11KJ11'f'P RBLAflO. HIP TO DECBASRD (Yp. eo or wkw~rw) U ytr. O~ve ~aas, datta oJ ~erv~cc) . ~ 18. CAtJSE OF DE/l'!!i (8wter orlr one ca~uc ~er li~~ los (s). jb) ~wd (r).J ~~~ta~if. ~crsrtv ~ e iain- PART 1. D£ATH WAS CAUSED BY: ~ - J p ~ 1 ~x~er n.w ~rwre i: P it~tMEDlATE CAUSE (af `~~L•~L. f~4_~.r.i4.~1"Lf G~~~"~CLaiJ maaen! ~ ~ „ co,a.~d.., .f DUE TO (b) ~ ~t ' t;.x_~~f G ' ~ r~ ~ 1'~.` • 1' ~rh~ch oare rise to ~ J sbox car~t (e), - ' .tatuo the wwdu- DUE TO (e) 1 ~w tar~e last. ~ 1'ART 11. OTIlEA S/QN/YICANT OO~iDITi01(S a,Knu~r~~e m wrN scr .ror uu~v ~o rne ~v~ar.u, nauss w~~~nox c~nx ~x rur t(e) ~ ~ r ~ ~ ~ 19. WAS AUTOpSY ~ C`~"C/~ ~ ~i ~ u-t,~~ PEAFO t1IDT ~ ~ L • ~s ~ NO ~ - are !o ~ ~O- ~~DENT SUICIDE HOMICIDE 20D. DESCRIBE HOW INnJAY OC(.'UARID. {gwter Mtrrs eJ iwj~vlr iw P~rt / w R.t l ol 'usw /~J e dnd v ? ? ? Vq IN~URY a_ .~i. ~ ~ r~ ~ it i. s~. . ~ 20d. INIURY OOCUARID 20a. PLACE OF 1NIlJRY (e. iw or sbort Aone. 201. CM. 'DOWN. OR IACATiON COUN7Y ST iE l~rw, /ocdrry, NroN, o~es 6GdI., etc.) R'MLLi iT ~ ~iK ~Npi ~ ~ ~ _ r'OlK ~T M'O~t . ' 21. 1 awsd~d Wi d~cq~ t~o~a . ^ b ' ewd lml ww ~ allry on D~dA id at ; S ~ es ~N daM staMd aDst~: od ~ 0~ b~s1 e[ isowMdq~. teai ~-earsN s1aMd. 220. SIGNII E ~ ! 22h A°~ RESS /c ~ 22c. ` A ,~GNED ~ i% G ~ n. ti ~ ` (..~~LIiL-G -j~tl~ 23tr_ BUHlAI.! 0 23b. QkTE ~ 23c. NAMB OF CEAIET~iY OR CREMATORY 23d,1~CAT10N (C~ty, ~o~ow, w cvrwtr) (Statt) CHCI~lAT10N ~J , ~ i I~ RE1dOVAL c7. i~ .Z ~/~i > 1~~ L/_ A r'~(.~' . .l". ~ L i'=! / 24. FUNE'A/1L C( : ,-i! ~ : f I. = ~ ~ ' ' t`' % /i` RDGISTRATIQr7 _ r /1DDRESS ~ i~,ti" 1•L 7 ~~J i l~ •'C ,f t i(,~ ~'A- NUTABFR~ ~~f~-'.~?^~ !_1 REMARKS: fILEtZ~SN~ 8,:~+)R~E4 RGCc a p „i7~ltS 2 . ~ - . 15~ CtE~' i:' C3~T CaOR~ ti.: . . , ~..,~3 : ; ~ _ ~ ZI 1~ sa ~k ' _ _ . . 3 ? } ' `F: r y 1 . ~y`.... `i,,~,..~~~ ~ y \ ' ' . _ ' ' _ ' _ _ ~'1 a' it-i- - -t ~ ~ . , ~ • i ~ • ( ~ ~ . ~ ~ ~ "Y Ii`-~ - - . .l ~ + ~ Provided it bears the I.~IYRF.~ED S~.AL the D~'~~t~ict'oY:Ca2iuntii~:~epartTFnf ~!'`f:~~;~c Hea1Lh and shows no evidence of erasures or a1te~~~}-;Qns, it is cet~ed LY:~:~. tte atuv~• ~.s a true and correct reproduction of thr ori~inal ~eff;,~.~icate fi~eet` i~f 'e t'? : Section o: that Department. ~ _ r=~-;~ ~ " 'j ~ ' . ~ ~I• i. ~ ~ f ~ ~ ~ e„i~0 G~3t1COli B~OK 218 PACE~s~o 'Chief "`Vital Sta 'st ~~'•P t i • , tl ic c.,_on $~~-t - ~ ~ ~ ~~~s.~~„~-~-`~'~'`T_...~ : -~x~.~~9~