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HomeMy WebLinkAbout0818 r. -~n~E or ,«~r.v.s 264994 ~ ;~.;;~:~~r ~:o. i~•32 ~ ~E 1~~R E~ S~fl CORONER'S CERTIFICATE OF DEATH DECEAS~D-NAME ~ust M~owe ~wsr SEX DATE OF DEATM wo~+TM. o~~. rw~ ii~~S ~tnffPrs ;i.'a]_e 3. SP, t. 1~~ ~ 1 RnCc ~~H~rt r.ccqo. wMeR~cwN u.wuy AGE-twsT • UNDER 1 YEAR• UNDER 1 DAY D/~TE OF BIRTH wn~*K a~r, ?w~ PUCE OF OEATM ~~Tr crc. ~sDCU~v~ ~~~T~awv ~vRS1~ p AWS. ~ AAYS : MOIrRS • NuN. p p s. ' fl l t:E' So. C)7 ~ Sb. ' : Sc. ' 6?~ nV . ~ l~)~') 70. ~:!ln~r i.TY, 1VN'a. 1MI O4 ROAD O~STq~CT NUNyER ~~NS'DE C1TY ~ MOShTAL dl OTH(R /NSTfTUT1pH-!lAMF ~~i?qTINI1TNQGVESTIItiTANON11MWl~ ~ ,lr[3/r+01 - ' i 7b. ~~~li ~t+n ?~nj rv~f;S '7c. V~'•S ;7d. ,~j}; .T~~Yf~.S' NC1~`tll t:~~ • i BrRTiiP~ACE uur[ pe spti+cN CITlZEN OF WHAT COUN7RY MARRIEO, NEVER•MARRIEO, NAME OF SURVIVING SPOl15E ~wu0o~wwc.~rtmr4 'OC"'T'~~' W?OOWEO, DIVORCED~vtasr~ 8. ':..,.,..,n...,r 9. iTC 1 10. '.t~ l~n•.rFaf~ ~ 11. S~:GAI SEC~RI7Y NUMBER ~USUA OCCUPATION ; K~eiD OF BUS~NESS OR {NOUSTRY ; V.S. W/1R VFTERAN~ WAR OR DA7E5 OF SERVIGE r~tet~ ;•ed ; ~~~fs,•~, . 11.'lfil_'~1~~'~(~?a+1 ~,so.~utcher '13b. (~~.~r~ ~•)e"1r~c+cq ~13c. *j~ ;13d_ ~tcS~D~NCE srwtt ; ca,Nrr `(~Tr_ ipwp. TM. p1 lp~p pftlKT NO. ' ir,s~ocuTr i STR[ET ANO NUM~[R . • ; ~rES/ta01 a~ '7 ~ ' ~i 14b. rfln~' :14c r'~'~ T'nr°~+; • 14d.Vr'S '14e. ~l (1 (1.~~r..tr1'1/~ T2~ !l~ _ ~ r A i r~ER-NAME ~~~sT woo~E usr _ AApTNER-rNAlDfN NA/NF sMST ~uDO?[ wt •c i^~1~~.~v. C1'nf'~f'nrn , _ R~rtha ~~1)(`,}'1 i ~tVfOtiMANT'S SiGNATURE ~ , RELATtOiVSHIP ~ MAII{NG AODRESS lsT~cET/ ~~no wo- o~ r- o, GiY OR TOWN, STATf, 21t; ~~4 i ~ "i\1'1 ; ~7!s-~~ CV~nn+.i,~~l: -1~~t~3-i.: ` n. ' y ' il Gt~A.1~-• • V G~L~U. \ ~~'3^ yl~I Y~ : s lo". ~~ATH WAS C/1USE0 BY: 1[Nru a.iv ~NE UuSE iEA UnE iql {a1. tel. (Nj ~rnos~~.~t~ ~rruvw~ asruti o~+str ww a.rH VART I. ~uMED~ATE CAUlk ~ ~ ST LUCIE C UNRAS l~ ~~Q * ;a~ ~1CIjf[~ ~(l~'+p-~ r+~ Tnr rnt~. ; Da.d TO. OR nS A CO~.S[qtEhCE O~ CLEFtR CI~ UI Q ~`r~_Q ~ ::~~•.,,T~o~.s A'vv ` , RECOFDVER;f ED~ v~ ~ T~ _:rterio~~l~r~ti~ F?eart ~isea~e ~ ~s~~•i:.A7f Cw`..E o1 • ' : 7-.E ~tiDiq. D~:f t0. Wt AS A COl.SEQVEKE O~ ~ ~~.Wi CAUSE IAST. ~ 1 ocj 3 I o6 aH 73 ~ _ c~f ; .'/1FT ii. p7ncR S~GN~FiCAN7 COND1710NS: co~.ar~~.s ccw.¦.~~r,..~ .o ct,r,. sur ~.or .~..no .o c.vx c.~c~ ;ti ..~r AUTOPSY - YES. wn .,r,.•.,S ~r. . • (YfL+vO) `~••n aTUr.«:wG c.uw ~ e• u~r.. ~ 190. ~ 19b. - -,E +~~-:~i • DATE OF ~N1URY~MO..TH QAY, VEARr HOUR . nOW INJURY O~CURRED ~~~+Tf~ N~iW( pf tNlV~~ MMt,o..ra,.. o... ~ . l~.: t i[C~M~.~,fJ ~:i'kC1{Y/ fq yA~T ~I IiIM F - 'Gh. 20c. M. ' 20d. 1N!URl' A: ~~'ORK~PLACE QF ih1VRY ~r ~.,;MC r.ow gra[cr • LOCATIOiV ~ ~utr, v~t dt TOWN; p! 7WR pR !D. WST NO: COUe.Tr; Siw~E~ • f~LtJ3~. Lf{~_t 6l.~lO~*~G (TC ISV[~_~ir. ' i'' ~i11 2~7. ~ . i T1UT ~N ~~Y O~I\~J4. BA~ED t~aJ : Mv e.~viST~i.~r~.o~. ' 7~E ~CEUtNT WI1S PRONOUNCEO DE/?D N ~ AT - T~~( ~r.~•+i~c ,~ON. T~~~S p[AT~~ p~CUaqEO ON T~~E DATE. ~~T~ DAY ~EwR t~~~ cl~tE Ar.D c~n i0 T~SE C~uSE(S; STATFO. whD Tr~/tT .~Ib. 9 1~~ 1!~']~ ; 2tC- 7~ II ~ PM. ~vi:0`ER'~ SG1tATUFE ; DATE SIGNEO iMOr.rM. owv_ v[~~s ~ ; : . :r-_ T _~-~.+~.~?w ; s2b. . .i'~:cti = w r~ >.~IAA. S ~NATV 7E ~ ! / : OATE SIGNED (MOf+TN. DAN, YFAR: ' i " , 23b. / " c~:~~tin(;.~. ~ ;CcMETERY OR CREhMTORY-NAME ; LOCATOON~ unr a~ row.. STATE A E ~Ma+TH. 4/ ri+,~lJVAL .u'i~~rii . ~s.r.~.s.-, ....i. ~ ~21A. j~~r+~ ^r~ntil~if-nv.~r '24c ~~1+~r ^~»Ip~• 111 l ~]/1l ~ 24d ~ ( t:~„tRAL 1ivME NMAE STRC[T A[10 NUMbER OR IL f. O. G~ OII TpWH ~ Sr~iE Z~r 75u. ^ 4.. e~. T r) ~ T•?pe; t-..~r~ { N n»n c t-. T~ ~ l»~1l S e~(l~~ ~i~j - ~r P ~r1 ~~iNERI1l UlRfG70R's S~wyATURE ~ .iIiNERAL pIIECTORT ~UINpS UCENSE NUM!(R , - ~ ' ~ 1 ' , r • .e. . IY~-'~ ~ 25e.11~~"~7 ;~~~n~ ~;c~~s'~n- s sw:v,~~uk~~ „ ~ , DA7E REC'~. BY LOCAL REW RAR~-~•+- ~7''`.~-~~~~ _ ~ 26b. 9-16-71 ~ '~`-~~y~tll ili IS P~itTMfrvT 6i V~BUG HE~ITH ~ 84RE~U Of STATiST.~i (BASEO ON 196t V. S- STwNOARD CERT~fICATi~ 3 3 . ~ ~ I ~ • / I~tereb~? ~F.lp ~£y`-~1~~C the foregoing is a true and correct copy of the d~~~~P~~~~~~~~' ;,the decedent in item.No. I and that this reco~:, ;t:t_ .~'b,~~d and filed ln my office in accordance with the ~ ~co~~¢"Illinois Statutes relating to the registration o€ ~ii~~ ia~d stillbirths . ~ - ~ , _ ~ ~ DATE+ : - ~ SIGNED. ` ; •.,~r. ~ --.t •~a ' G ~ :y~, • • AT : Chic~dg~,:~'gh~~,~.l,~,y_ ~ TITLE :.,.?.pf~AL I~Erf;IST~1l~t- BOOK 7 rAGE O~~ . . It ~ ~.r, _ - _ - ~ _ . _ . „