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HomeMy WebLinkAbout2227 NEW YORK STATE ~ v ,aco~o 0 0~ ,~~c, sr.~i •~~c wuM~[¦ ~ i . ~ G~ / / DEPARTMENT OF HEALTH BUREAU OF VITAL RECOROS 2'~438~ , o~v~s o~1 •~~i~res ;~;t~~ ~ CERTIFICATE OF DEATH i.~ ' ; t f~~) ~ TYPE ALL ENTRIES OR PRINT IN PERMANENT BLACK INK. •,~t: 1. NAME• F~RST MIOO~,E LAST 2. !ti 7?. D~T[ O~ OC~Tw ~B. MOY~ , ?+~1~ IW~I[ vOMtN G~• •c~w ~„T.,~. , , O ~ ~ ~ ~ O 1 2 ~ / M' ~ ~i ¦~CC: Iwr~*[. w(c~o. S. •CC ~r urO~w 1 r~. ~r uro[s O~. oA. Y!t[IIUI 01 U-S. A~~A[O IO~C[!• !B. ~Cf-l~tt~/~ wa~, O¦ ~M~~IC~Y IYOIUI. ~T~.~ ~IDMTM3r~t~1 MDYA~ ~IIN. ' ~~7~s ~~Ar~« ~ MO YMRNONN ' • t.` a ~ /`~LC`IJ .~a ' ~ ? ~ ? ~ 4 J 1A. couwtr iNtl51 11B_ •owM ~ 7C. c~i• o~ vlllaic~t0. lCwirw or ~t~t ~w ~7E. Mos'~~~1 0~ otM[P ~w!?~tuT~Ow t I I 1 TOwM~ C/Tt OA YIIIAG[' I11 I~[IiM[A. CIVC STII~CT ~ MO.I u ~ ~ i~ i ~ ~ ROSWELL PARK MEMORIAI INSTITUTE ..y. V ~ ~ O ~ ~.17~t( 01 •IAtM. O~CfO[4• •OAM IO ~1~M O~ AM~T ~i. Y~¦ ~l lT~TY~ IZ. ~UAV~YIM{ ~~OVSC I1/ wl/[. /I~10«I M~Y[.I ~ ~COYNTA?,IfM07Y!• YOVIr O~? ?(~~1 COUMTAt1 - ~ ~ f ~Q~~'~-,t,a,i ia ~i~ ~,~l~L. `~t.c~-~<<,~. ` ~ 1D~.. usu~t otcu~~T~oM 1[v[r ~ct~w[o~ , 1)B. atro o? ~u~~wcs~ o~ ~~oul~~r ' ` 1~C. loci~l [cu~~T~ wo. ~ : ~ti~~ I <v 'P?L,c.,~c ' ' D x.v ~3G9- ~.3~ ~ urts. f~A. li~7C ~~0. COUMt? I~C_ ?o~r ~ I~D. C~~? O¦ wllact I~E. N~tw~,1 iw~ UF. !iA[[7 u~0 Mu?~?t¦ ~ue ~r y 1 ? ~ ~ 1 co~~o~~~c u.~~tat I ~,.c .c~~. ~ ~ iv'st a~~ ~~ss~ ~ ~ ~ 1/~~ ~ r[! Mo ' V~.~~~ , . i ~ C ~ ~ ~ ? ~ : s i a~ ~ ~ ilA. ti~w[= 1~p1?~OTMC~'! M~~OC~ MAY[: 'I 4 •~~fT u~ool[ lwsr r~w!• uloOl[ LUar 4 = ' , • l ~ - ~ ~ : i ~ IOA_ IM~OAM~Niw~3 N~N(: I~~. MAILIMG ADOACI3: IIMCLYDC 2/~ COpCI i , ~G~/'vRN ~/74~"'~/ ~ , ~ ~ y+ru ~or[o w ~ 666 EtM ST~ . r ~.nu.e.i ~ccc.. I~~ . 6UFiAtO. N. Y. 11203 t {+aw~...¦ . co~. ~ i ~+.iv~c?t[uar~c : i ~ - PAQT 1. O[A7N w~! ~~U![O ~t C47[11 OMI~ OM[ CAYSC ~CA liM[ •o~ IA1, IBI. I~wO IC1- •~~wOR~u~1[ IMT[AYAL . ~(TM[(ti OMS[T • OC~1TM ~ ~ ~tt CIRTI/~. 17. liuu[DI~T( C~Y![ . - ~ ~ ~ ~1/ UU lCC[~T~O ' ~ ~ ~ Prima carcinoma of left female mamma 1 d 16 months ~K o~c ro o• w~ • couaco~cwcc or ~ towo~T~ows, v wr~, wM~tw N~ti~'1 IG9trQ.7tia$89• f~ ~ ~ Gwrt w~lC TO Iuw(O~~tt Ipl , : C~VS[ l~~ ltA~1MG Ta[ py~ ~O O~ A! I~ COM![00[NC[ 01 ~ ' YMOtRt71Ni C~Vf[ LA7T j ~ ~ ICI ~ ' ~ ~ ~ PART ~i_ OTM(II lIGNI/IC~M? CO~IOIt~OMl: COMOIT/ON7 CONTIIIWtIMG TO I~A. ~YT0~3~~ 1~8. 1/~C!•MCAC r~MO1Mi! COMlIOtll[O IM ~ ~ OC~iM •V~ MOT ACLA~CO TO C~US[ G~v(M IM I IA1 3 MO ' O[T[~~~NINC TM[ C~Y![ O~ O[~/MT ~ i ~7 ~ 2 ~ I T[f'-' MO ~ ~ i= O 1 2 lLl ~ i ~ HA. •tc~o[M~, wo~+~t~0[. IYB. uo~tn o~? •c~w tOC. Mou• 1~D. wow o~o ~wiu~~ Otcuw/ ~twt[~ rwTU~c o? ~w~v~~p ~w +17 o~ ~I.~ ~ ~ ~ V lVtC~O[. YMD[T[~wIMCO I , ~ . ~ ~ _ 1 1 1 ~ ~ IOE. INJ:J~? AT w0~~1 IYF. •l~C[ 0/ IMlu11~. M04[. 19G. LOC~110M (l~1~[[T ~ MO.. CITY O• YItI~GC. TOiNM. COYMT~. lTAT(1 ~ ~ r ~ Q MO 1 /ACTO~Y. O/fICC •IOG.. C~C. 1 ~ O u ? ~ ~ ~i ~ ;r:~~ ~ TO BE COMPLETED BY _pR_ TO BE COMPLETEO BY , ~ " 20. PART ~ CERTIFYING PMYSIU/W QNLY 20. PART 11 CORONER OR MEDICAL EXAMINER ONLY ~i ~ ~T . ~ A.TO TM[ ~[ST O~ M• RMORL~OGC. O[~TN occu~~to A, OM TM[ ~AS13 OI CI~NIMI~t~QM ~IID/OA ~MY(SIICATIOM. 11~ MT ~ ~';y V TMC t1At OA*[ ~~O,/l~C[ ~NO OV[ TO TMC MOMTM O~• r[~w O~IMION O[ATM OCCVAA[O •T tM[ Ti6/[. DAT[ ~MO ~lA~( ~MO ~~ti7: ~ ~ uus~a s?rco 1~ 1 DY[ TO TN[ C4VS[3 lTAT[O. ~ ~ I . ._.s• • ~ . ~ ~ ~;S ~ ~ ~ i ~ . '1.~: f , ' • . ' ' ' ' . / I ~ ~ 31 GM CO."'...."' ' „r. lIGNCO..I.. ..~...w". . . . . TITI[............._.... ~ Q~ i . ~.Xf F - - B. 7MC /M~SICI~M A7T[MD[O TM( OCCC~S[O C. L~ST SC(M •LIYC B. ~~ONOYMC(O OC~O C. NOYO O. D~TC l~GMCO ~ } d'y{' . w011TM D~• [~11 MOMiM 01? •[~A MOMl~ OA~ •C~A 40NTM O~? •L~~1 MOY~N Dl1t 7(~P ` 1 ~ ~ 1' . ~ , / 1 I 1 1 1 f„~ '_i~t ~7,'~ ?1104. ~ ~ i / / t0: / 1 ~ ~ • OM ~ A~ M. ~ ~ f ax ' N ~ ~ ~ ~ O. w r r t~ o~ w c s~ c~ww. ir oTHCw r«~w c~T~n[~: E. co~oMU's rw~s~ci~w. orw[• ~Naw c[~rv~u~ ROSWfti PARK MEMORIAL iNSTITUT `i : ~ ~-~5 ~ , ~ 1r~`t~~ 2I. U~f1[ AMO G~ElS I~[~IT~I/[11 I~M/llClu~ COAOw[A, MCOIC~I [tA1dIM[11. COIIOM[11'! /M7/SICIAN. MCOIC~I OIIICCTOI~I" I ~ ~ohn ~I. Pickren M.b. ~ ~ 666 ELM ST., BUFfAlO, N. Y.1~1201 ~ ~ - - l2A. ~u~~~~ t~[~~*~ow s[~ov~~ MOMTM o~r ?c~~ 220. •~~t[ or W11~~1. C/1(I.~ATION OA A[MOY~I 22C_ LOCwT~Ow Ic~t7 O~ towu. lt~itl ~ ~ ~ ~ ! 1 1 ~ ' t'{ 1 ~ Z~A. M~M[ ANO ~DOA[~! 01 IYM[AAL MOM~ 2~0. [itlT11? M MO- ~ / ? ~ ~ . ~ , L / r ~ iI.^ S;l , ~ ~'J , _ ~ ~?>i,,.u: ~ ~ ~ fp:•v~c Vn~-.~s- ~,~l~`.•~. L. , , ~ . . ~ ~ t , ~?s~~ ~ 24A. Nu+[ O~ ~YM[w/1< 0~11[CTO~ lIGMATV~t O~ ~YMCAAL OIIICCTO¦ 24G. 11[i1~t11Ar10M FO. ' - . ~ JlN~e c j- ~y~ ~~I ~c: ~ ~.,r.:`~- ~ ir • ~ / : aR r' - r~~j 26 • w~ru 0? A[61l111~1A • O• MOMTM O~t •[All j~A. • r1AL O~I II[MOY~L ~[AMIT 1!lYtO 200. MOMTM D~1 •[AA . ~ ~ r~~co 1 ,._r,; _ ~ ~l ~ ' . . . JP~PL .x. . s~:~ 1~ . ' ^ ~ 4. : ~~~d / - 3~ ~ ' p GG~ PAGE 1. Subregi atrar • 'u ~ { ~