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HomeMy WebLinkAbout0585 . FEE RECEIPT NO. ~.f~ ~ 7 3/ ~6'7~Z?s STATE OF Il~lNOIS - DEPARTMENT OF PUBLIC HEALTH - C E R T I F 1 E D C O P Y O F A D E A T H R E C O R D , •t:~1TRqTItNd ~ ~~AT! 0/ (LLINOI~ ' ~wwiii ~ ~ ~,~,~,~T s~4.o _ s$- o a 3 0 0 ~(G+STlRtO MEDICAL CERTIFlCATE OF DEATH hl'YBLR a~aw?a A.N ?uut rwuat w~ !!X DAtI (!1 UlA1N w~•.o~, wv, ,w, ~av.~ , 9RVl.n Sirt eit ,l?''a~LE /t ~ S ~9G8 ~ i~L ~ttr0. ~uw4~w wau1, ~~~:~a~~VNOLS:~YEAM- H~ltER 1 DAV p/?iE O IR~H ~~~~?r.~nw Y~%?C( pF (?LAiM cQ,.,i~ ~ fL _ .~E ~ ~w? ~ a?.~ . iw+q~ . a /Lt•z so. !SO ~ 's~. ~ e. ~ . TU' 1 " 7d: l~icoit c~~r, ~a.~a iM. w.wo auaKr aw.~u ~N.ua utr ~ 10V~TK O~ OTWI MATQYTWq~1YW ari+ot w utw~.~w ~uur ~..o ..~.?~u, ~p~u ,a Occdt~u ~ ~~a. ~UabQ,eh ~~a~,ta.l No~ BUIT?+VLA:E ~?~.~i n~o~uw CITI2EN f t COUNTRY MARAIEd NEV[R MARRI[D. NAME ~NG SPOUS[ ly wr1, iw~ au~py cu~...~a.~ W1pp Eb OIV EOtvica~rl 9~t,d.iana o U. S. r1. ,a /~'~`e°~ - Fii.e.i.~a /11.1en SOCIAL 1[CUR:TY ttVMBER ~SlI OCGUPATION . 1un0 Oi tvS~Htii On IMIxKT1tY ~U.S. WAR YET[ . WwR OR DAtES Oi S[RYtCE _ . ~ ~)..07-2~16 ~ ~nee~ : ~ wa6cr,eh. . : ~ a~ ~ No ~ ~ ~e. RkS10ilVCE uwtt ; cow+v ~a~r. ~o.+a ~r?. w~we w~rrcr wa ~ w~s~o~c~Tr ~ f~atn ww ~wrrut Qw~.wM,~ . /~~~r~~ . lrtt ~ i1n. 'llb. •""4v~w ~Itt.•"'C'~.6C.~/ :IId. `IJ~~~O~ . : . • Qvx M e+lit-Nwn~ ~~asr ~woou wr t1E n1 M ~Mif .~ok~ ~ w~ " ,s. DP.C6e~r,t Sic ~t , /fcrivials eic i?a O~tM/~N • i UR ~ RElAT10NSHIP ~ MA1 'NG ADOR p~u~T ww w. oa t t. Rc~t~ ca ~a.w, s~w~~, to~ ~ fl' ~ .~r~;~,1e,~lJ b w~ e ~ „~.0. l3ox !~?exi,co 9ad~?ra 46958 - YART 1. DEATH WAS CAUSEO Y: timu aar ONE cwusa ~?un ra w~ ~w. ~.o w~1 ••••~•.•••~u ~..n.Y.,a - ~ff~aitN G =::i M~ G.+TH a""'_ ~1. ~MM[0/A7l L • /~1,` ~a~ • ON~ TO OR Af A COM1[1'jV(M(t Gf ~ ~ ~ v COMO~T1b~S. II AMr ~ ..~rc.. uv~ •rx ~d wvt^u?1i CJ~v( ~ ~twtitiG TNE uhOla. py~ Tp p~ AS A tONf4QVIM! pt l1'WG GAYSL WT. << YNtT 11. OYMfR S~GNIf1CJ?NT CONCITIONS: w~Tas cam~wrwa w ou*N «rt ~o? ~uw~a to cww M.w «?.~r ~~y AUTOPSY r~~. cw- . ~t~?~ ~ ~i~•~e .r w~aM+.+r. (hA[ ~ aI M~~~ ~ ~TE,qF oP qY~ i.~ ~r+ f~Ha~ of orcnwYiorr ~~~t,v~~vrsl . . ~~~tC ~ • 1~E IFY tHAT TO TME BEST OF Irt1/ KNOW~EDGE TMlS OfATH OCCNi~itED AT /oA,, NOTE: IF AN INIURY WwS INYOtVfQ 1N ON THf QAT AT TME PLACE AN~ fROM THE C/1USE(S! STATEp J' ?M~5 OEATH TiiE GORONFR MilST 2~, ~ BE NOTtF([d. ! /t..f!s~9 Y: ~*rrM . e•r • vc•~ a.r . wa ~ µ~i~ Nrt/ M• . 'x•• DfCEASED FROM• : 5 : ~/i~TO ~ i '2 : ~Vf ~ : ~ 21a « 21b. • 21e. ~ ~ S~6?~~1Z1J0. ~ ,Ir~~. . W1TE E~ wonM wr.~ . IIlINO1S_ UC~ Sq€ ~ ~J (/V~ ~ ~ ~ , 'T rte.~' ~ zm. ~o ~~l6 : ~:~3 t~ - I~wL~t:G wCL:fSy-{ER1if/fR uu~r ~.o u w a r. a os Torm ~r~•[ tr 2~s-a r~. l~[~a.~,~-5~ ~CC . ~~s~'_ buk~~l, 4E~nw ~ . EMEIEKY R MA O . uTr aa rowa uwu iw~.~n, w•. .a..~ ;.,'.~l~'~ru.ia:l' ~s.,~udc~eeh (~JianP.l Fwl,~on Coc~rt,t~, 9n~C'a.tac ;,.4.~'tu}• c4, 196c3 iWlLl{AL HCNRC NMA flllti AMO MrW~~t OR I. 0. GT? q IOWM {tAT~ tN . f. I~baan. 8 Son.e 4$6 N. wcr.trlt Deur.fuit 9.~,l.ilcoLe 6'252,~- ILNtAA ~i 'S S1W TU~ - .~w+uw o.~~c~~+s M~wa~ uuwu w..~~• „ : . . . F~ if~ Y..~ w~u. k~a:.~..K~• uv~~ uae ~ A L N~ ' YY LO(AL RlW~1N ~ , . i ~ ' ~ `~1 ~ i~ ' b / ' j ' ~ . / YSZG4-(~%(.C) Nirr/p: p~~~lrl~ft GI h,~lK NIAIiN ~ t1Af t~ - I~~f~U • Ipf V i?lw ~aD C~R7.~.G~iti : : , y.~, o : - -~t ~ - . r •t , - ; 1: r t . . ~ ~ . .~f~: : ~ -S . ' • . t HBREBYCERTTFY THAT tke jor~going is a tn~e arrd'~~! o' ~r ~ ~}itq~bC' f dtith as mode fiom tht os~.bm[ certificote of dcath for tbe d~ced~»t r~amed thesein and that' h~srb of Pr~blic Htdtle in atcosda~ce witA tke statutes of 111inois. ~~~u~~j~~d with tbe Dspsriment SPRINGFIE F,L_[, = .^C~~D ~ ` • , ' LD Sz i~,- , _y ~ F[.a. . ~ ' j_~ ,/l _ ' . . ~ iT . ~ ~ ~'G /,~',~v O CT 1 9 19 . Q,~ ~ ` ` ce C. L.ashof. MD. + k~• Director of Pubiic Health and . G~ 1[Q i l 0?1 r~~ ~ 3 Stete Registrx U R~~(2 {~C~ ~4~ /+~+~i,~>< <,:rr~-r,n~d~nce about vitat records to the Offioe of Vital Reoords, D 8~~~ fJ Q ePartme~t of Public Health, Springfield 627~1 F:. ~~rs. . _~cx" . , " _ " S H,... . _ -:'3