HomeMy WebLinkAbout0711 . ~ . _
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~ s '`Geor~ia lkpartinent c~f Human Resc?urces
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CER'fIFICATE UF DEATH Siat• Fil~ Ne-
~ DIATf! NO. idilitia D'ut. Ne. Custodian s Na
i l. HAME OF lPirsl) lMiddli) ~ (1.~1) 2. DOFTE (Mon{L) IGaT) (~u)
~ DECEASED I~ R. ~ ~ ~ sT ~ ~ DEATH~~`a ~ q~3
~ IT~P~ er PrioU N
. PLAC D TH ( oaatT) i AL RESlDENC6 (WL~~~ d~c~as~d ti~~d. U~ostitutioa: t~Md~nc~ D~ler~ admi~rioe
~wiNl,ieTr" I ~.l%a;dA ~o,,,,, . cic I
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CieT w To In C~i Limi~. LENGiH OF • YN Q~ !le lSTAY lia Wis Dl~e~)
7~~ ~ No [j ~ ~SIAY~(~~e~Ih~is Pi~e~) Cit~ ot T
~1~ Q~ __,___~„~^'~s ?own- QR 1 _ ~ RCe _ yQs
Haa Hwp• O~ Iestitutiea LE.lJG1H OF $trNt Addrw~ or R.F.D. asd Se:
Ne.
v~e,~d ~t~e~tAL yosP~TqG ~~hre~~71Rs :~~Il Q' ~R. 3 3 4So
5. SEX i. HJ1CE 7. Di8 LA E( t~t~ o+ loi~iqn coua~q)' Ctt[ZEN OF WHA7 ~y,
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~ COUNTHY? RIIrlOVAL ? ~
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! DA1E OF DIATH 9. AGE (in y~an)' IF UNDt]t 1 YEAR W UlIDER 14 H[iS. HM[E OF F~~7EBY LOCATI01i (Cit~ ar i~wn) (Countr) (Stat~) ~
tut b' da~ Months Dar Hour~ Miu. F ~
~cb • 189 y ~ ~ ~ ~ Qs ~ C'r~~TtR ( $v~a~ NNe7r GR .
10. MAlIAIED NEVER :iARAI ) 11 Marri~d ot Widow~d Gi~~ Nam oi Spou~• 17 ALMEA'S SIGN 8E C NO.
~ WIDOWE~DN08CED p _ `E CC ~7 ~~~RN ~ ~ /
SEPI~~AtED p i~~
I1. US0J1L OCCOPA7ION (Gi-~ bnd ol worlt ~CIND CF DDSQ?Si9 OH OFTIC
don~ dun~n moU o! worlcii. lil~. ~~~a it i~tir~d)~[IiDU~STBY .
4' ~XCCsT,~o~~rRltl. h1oT-o~cS r4~_~ a1!'Rr4~ a~nc
~ lZ. WAS DECEASED EYEA IN U. S. ARMiED FOACES?~ SOCIAL SECUHI7Y HO. 19. NOBTICiAN'S ADDA~4S
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(Y~~, uo, or .:ekoewa (U 7~~• 9~~~ war or daf~~ 07 ur~ic~)
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GN~A OwG ' ~ ~tIC.C G ~ /"~0~1~l9
~ ZZ. CAUSE OF DE117H I~~~~ ao1T en~ ~ ~t lis~ !or Ib FLEASE PR~NL RVAL dETWEEN DO O WAITE W lH1S SPAC
E; PABI 1. DEATH WAS CAUSED 3Y: ~ ~ ONSET AND DEATN ~ l. I
~ .,~~-•f~=, ~~r~.~~. _r - ;
IMMF.DIA7E CAUSE (a)
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i I ~t~"[~"~`!_.i~ ~l'~¢_~ ~CZ_w..d~ ~ .
Cond;~ion~. J aa1. DUE TO (b) ~
C~~ O .vF.ich q~~~ ri~~ 'o ` -I S. ~ 6. .
' :i G abo~• caus~ (~1.
i t ¦!anaq th~ und~t- ~
E S; I~~nQ c~uu la~t_ DITE TO (cl = - - - -
~ PAN2 U. ~ r uqn~6canl coadi~ion~ conln6~tia7 !o d~alh but nol ydat~d to Ih~ I~rmiaat di~u~ conrJiaon pi~~n in Part I(a) 23. AUTOPSY7
~ C' ~ ) ~ i-~ J~
~ i_. . u / < = ~l~ _ 1l~~ No (7
~ U7 ' U ACCIDE~' [~•PLACE OF lNJUR7 h.q.. iu or ~bnul I2110HY OCCUR9ED i _
~ SUIC~Iil~ (~ihom~. tsreu. tattory. dr~eb Whil~ a'k Worlr Q~- ~ n~nb~? t~rfilr 1La! I aN~nd~d 16~ d~t~aa~d !rom
U HOMICIDE oilic~ btdq.. s!c.) No1 WkiL a1 Work l9_ , fo. 19 . 1Dat I Lsf saw 16~ d~c~~~~d
! ° (CIiY OR 70WN) (COUNTYr (STA7E) ~ TIME (Mcnth) (Day) (Y~ar) (Hourj ~
i ~ ; ~ - i ~F ~ ali~~ on . l9 and ~t
. : 1N:uq~ - d~at~ occup~ a~ m.. lroa th~ c~~is~s aa de 16~ dal• stet~d ~be~~.
~ HOW DID INIUHY OCCUA? - - - i~. g~G -~pE " D~~r~~ or Tf i
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; ~ 27. DATE NEC'D EY lOCAL 28. KFGiSTRAR S SIGt1 RE lIDDHESS " / ~ DhTE SIGtQEO ~
~ AE~~~~ t ~ , . _ l.~,L. f / ~ ` ,`i
, ~ ' -.i_:L~?~ ~ ~ ) ~ _.iJ
~ AS I 51 - 3 '
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f14ED ti':: ~:EGJnDED
REC. I I ST. W~i~~ ~::;~NTY FLA. !
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~ : - - ; ~i-~AS ~ '
~ i ~ CLFF.R . .
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s'' i State o£ Georgia QEC , 49 ~N'~3
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~ ; ~ co~ty o~ cwrrTrT~r~r 2'71369
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~~F~:' ~/I~~~ hereby certify that the foregoing i s a true and correct abstract
' ,~~~~~,j~•~~~~~.~~~~.!
r the facts of death as shoWn on a ermanent record of death on
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~ _ ~ ~ ~ , ~~'3s ~ ~2n this office.
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