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HomeMy WebLinkAbout2402 . . , - _ r.~,..,,;,~.., ~,;.7E ~ ~ . '~-~2.ZI . . ~.-.-c..~ a ~ • ~ . rt•~..~::.-.~- Jc.~!~4LTi'. ' ~~Q ~ 2'744'7~ e~~~h~ k~~~~os <<,F. ; . - o+••~~~o~ CERTIEIC/lTE OF DEATN - rn TYPE ALI. ENTRIES OR PRINT IN PERMANENT BLACK IHK. _ , ,-~J 1. NAME: FIRS. MIOOLE LAST 2. i[= 7A. OaTt O~ D[wTN ~ 39. w,u• - Y~LC /IYkC MOV1M D~? ?CI° --<tiSnCAL D~~1~~CT 4 • ~ Hort~n R. Gillen ~ ~ 3~14~ 73 M. ' ~ F tic ~ Ra~[- (BMIT[, M[iAO. 3. ~GC ~r vrocw 1 tw. ~r uwo[¦ ~ o~. 6A. r[tt~~w or U.i. ~~~co ro~[[st 6B. ~s res- s?[u~r waw, ow wr.c~~crw ~wau~, c~c.~ wow*MS~ o~vs wows ~ VIM. ; o~res or scwv~cc ~ ~ res ro urarown+ ~ I ~ E ~ ~ . White ~1 rwf. ~ i ? ~ Q ~ ~ . ~ • ~ . V 7R. COUMT~ INYSi 17p. TOM4 ~ 7C. CITf OA YIL~AC[,7D. LEMGTN pf sT~r IM ~7E. MOi~ITAI OR OTN[11 IMfTITU~IOM ~ ~ ' '~ON\, C~tr pw v~~~~it~ (1/ \~ITM(A. i1rC sTR[CT ~ M(`.) • ~ Orange ; ; Middlet~wr~ Life iMiddlet~v~rr tat~ os ~a] ; 0 /.ST~T[ O~' ~~ATM p. O[CCDC~iT •Ow~ ~0. CITIt~M O~ wN~T MAA~TAL iT~TY• ~Z. WAYIYIM~i siousc I~r K~/C. K~IDG. MAY[.~ ICONMt11V,liNOTYf• MOwiM D~~ Y[~~1 CWYTA~~ , _ -E _ ~ New York i 12 ; 4~ol U.S.A. Married C?ar~ Bell 17w_ usu~~ Octu~~T~ow 1[v[r ~[T~w[O/ ' 138. airo or wa~r[ss ow ~rDUatR~ I 1~C. sOC~w~ sCtcR~Tr ~.o. . 1 ~ ~ ~~.OZ Z? 2 i' 1 ~ ¦CLID[wCE MhLRC __:~.s[~ U~[D. If ~ 1sA. lT~tE 118. COYMT• 1~C. TOMiw ~ I~D. C/Tt OR Yill~it tsE. MITMI¦ TMt 1~c. 3'~EL~ ~:7 +J~i[w _v~'~ C.CtAI~[O IM ~ ~ ~ ~ I CO\~O~~tC I~YITf! ~ T ~ ~'~o?, t~V[ 11[il. V ~ 1 r.i ~ a~.~L'~ ~ =c~c~ e[sOt[ ADH~~f~O.~. ~ ~ ~ ~ `--i ~ 1ew York ~ Oran?e ~ 'Middlet~wn ~ O ~Edinbur h Ro. p ~1 ~5~. /~TM[A'f MYtC' iSB. YOTM[A'S Y~ID[M M~YC: E i 1111lT r~001t l~sT IllltT MIDDI[ L~:t ~ / i L~ t ATTENTION - / ' f isw. ~rrow.+u~T•s wuac: • ~t69. ~wu~~wc ~1D011[fi: i~wtlVC[ 2t~ COOU . E~.o~,. MOT[D~.. H~spitaZ Records , B~x 1453, Middletown, N, Y. 10940 v~ S . ri[~T~~[?OA[ACC[~. - J ~ ~ ' ' _ , . ' ' Z}} _r e. w[G~=tw7t1~'~rYO~- ' ~ ._=fen scasisaC~Tiarwi~- . ---~5 s~~ i V ita. I.~~M7i~?~tT? ~NT[I.v~~ 4 PART 1_ . DE~TM ~VAi.LAYt[D. ?T - [MTI11 OML~ OM[ CMISC tINE /0~1 IA~, 16~, A11D iCl. ~~T11~C[N OMS[T b D[~:M ~ .,tiCO~R[CT GCRTI/1. 17. IVU[OIAT[ C~L3[ a'E re~5 •[C11 ~I~tC[1T[D *~c ~cusr~~~, n?c ~w~qrteriosc? er~tic Cardiovascul T ~ 1 ~ _ u~.s. aa. ouc To o~ ~s.~ co.scouc«cc or • - ~ COKDITIOMf. Ii ~M7. wM1[M _ . GAYE RIS[ TO IMN[DIATC CAY3C 1~1 S~~TIMi T~+C YMDCRLYIMG C~YSC LAST OYC TO OO Af A CO~iCQYCMCC Of IGI PI.fiT 11. OTN[11 iliM1/IC~MT COMDITIOM9: CONOIf10~If COMTA1WT~nG TO I~A. ~UTO~ir! ~108. 1/rCi~W[~1[tIMO1Mif COMlIOCNLL 1~: : ~ Ot~TM •lT MO •LL~TCD TO C1WiC G~ [M Iw v? T 1(A1 •[S MO ~ Dft[R?~t~M1NG TNE CI~Yf[ Of y[/.TM• ~ Pu1m~nGry ~rnph sema C~ron~c o Psych~ses kith ~erebral A.rterios o,~ ~ ' ? ~ ~ ~ 1YA. ?CCID[MT, MOMICID[: ~~8. NOMtM OA~ ?[AA 19~- MOUA 19~. MOr? O~O ~rwwr OCCYA~ ~CMi[A MATyAC OF IMJURI[3 /M t17 1, OA II.1 ~ sY1CIDC_ YMOCTLAYIMCD ~ ~ 1 ~ 1 1 t ~ . ~ S1 . ~ M . ~ ~ 19E. ~M~uwr AT w0~11• IYF, •LA[C 0/ ~r~u~r. wow[, 19G. ~oC~T~ow IS1RC[T ~ MO-. CITI OA Y~ILI~GC, TOMM. LOY~fTti. fTATC1 •[t ¦O 1 /~CTOA11, O~/~C[ KOi.. [TC. 1 '.GV. V Q ~ ~ 1 ~ r ~ ' ~ TO BE COMPLETEO BY -0R_ TO BE COMPLETE~ BY _ " 20. PwRT 1 CERTIFYING PHYSICIAN ONLY jp_ O~RT 11 ~RONFR OR ME~ICAL EXAMIltER OKLY ~ ...TC iif: O~ .~~.w~[G:i, ~E~~w OLCUww[O ~T CM TN[ Y~S!S Of [i4~iMAT~Ow u~O~011 IMYCfTIG/.710~, ~M 'r!i W • TN[ 7s~![. OI.TF.AhD ItACI wNO CYC TC ~MC VpMTM •L• - O~INION DfAiM'OCCN!\CO ~t TM( l~M[~.D~T[ YIC ?I~CC AMD~ ~ ~ " ~ - ~ CaUf[! STAY;D - 1 OYC TO TNC C~YfE3 tiAt[p. ~ ~.Y:, TfTL[........-......... . s~cwco..~ ~vtM~se~~l • ~ ~ Z 73 s~cwco.....•-••_- r'„~ B. 7M[ ~w/S~C~~N •TT[wOCD TMC DECE~SCO C. «~T i[LM ~IIVE B. •~O+QYhC[D DCAO C. MOVA D. C~TE S•WLC ~ 1rOM7N O~~ E~¦ M04Tw CAt [~w ~OwT« O~? ?C~w uOrT~+'D~? ?E~w . ti.rTM~D~r ?[4F _ 1 1 1 / ~ • ' ' ~ r . /A6M" ~ i0: ~ 1 ~ • i OM t ~ ?T M. ~ ~ ; D_ ATTCwD~wG ~N~f~C~~ti, tI OTN[R ?NAN t[wT1~ICR: IE. C0~10M[11'S ~M~i1C1Y1, If OTM[R TMAM C[«1f~[A~ ~ ~ C . ~uemuel . _ ~ 21_ MaM[ 1W0 AOD~[!S Of C[11T~T:CR (~M~f~C111w. COwOMt~1, MEDIC~I E1/.YIM[R. CO~OM[II'f ~Mf51C1~h. NLOICAL D111[CTOA/: " ~ C . Auemuel M. D ~ - - - ~ W ~ ~ . ~ 22A. •VA1~ r[?~TIOM ~[MOV~ ~/OMi? D~~ VE~' 228. •lIC[ O• WAI~I. C11EM~TIOA 01 A~.Rw~ Z~'~.~OC~T~ON ICIr~ Or TOtiN. S7P:C) . ~~f.~ ~ ~ ? ? ~ ~ ~ ,3 .r G~,.,... ,v' . >'3,: M ~ 23A. N~ME •MC ADDALSS O~ • [11AL MOME , /O C , q~~ i 236. RccisT -~~ow w0. b d 1 ~ ~ < ~a-4.~~-t,h.c~.-~/% l ~ OI2Ci U ~ o' CJ/G . ~ 1 ~ j 2<A. N~M1[ Of •UM[11~1 O~RLCTO' ~ B ~~M~7r M , ~ GT tZIC. tEG!STA1~TiON MO- . ~ ~ ~i9.z°% l~`~/~G~~ ~r ..,,t?'~ ~ OSj// . . . a LL, : S S~fr~T~~E 0/ ~~c~•iT~~w 2'e• ~o~T~ a~r •c~w zsw. w t ~b co' /E2eB. Mo•r.l ~ar ~ ~ _ ~ j ~ Gl.tE i • • ; ~j~ ~ 1 ~y ( . ,a ~:w. wt'r_ l. ..a~'".. ` r. u 3 y~ ~ ¦ . . ......:.w ...".\JM~ rr ; a- , ~ • °