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HomeMy WebLinkAbout2896 2'~'69'74 ~t ~ ~ ~ OHtO DEPARTMENT OF HEALTH 'L R`i' N°' as DIVIStON OF VITAL STATISTICS y"" .~-r 9~ " Pr;marr Aes. D:u. No. ~ S G~~ RrR~sint's \o CERTIFICATE OF DEATH DECEASED-NAME ~.nr ~IidJlr L.x~ SEX DATE OF DEATH I.Mortb, Da~, Y~n1 or^ tr_• l-..•~.nc• ,-~_i(_-~~ ~ ' l~ _i. . L: ~ r..t.:•. _ RACE ~'b;ta, «s.o, rae,ir~~ AGE- t..,r u?+oeR i r[~e uNDEt t o~r OATE OF 6iRIN r.~t.,rrh. l~.n, COUNTY OF DEATH iydu~. efr. IS?ecef)1 ~i7 b..ib4~Y i~r.r.,l :?lo,. Dru Norrt .Ni~. ti~errl ~.~j:ITj~ So. 7~ Sb. Sc. 6. (1f`} r i~11(~ 7d'nh. i:~:~T~. O~ CITY, V~tIAGE. OR IOCATI~N OF OEATM INSfOE GITY 11M115 HOS~~TAI OR OTMER 1NSi1TU710N-NAME ~If w~f iw titb~r, ai~t ~Ir~t! a~d ~r~it?J ~ lSptriJ~ ~u o~ w~1 - ' . . 7D. •.n.Om:•j-T,^,~"~ ~ 7~ ~d: (1~~ '(^~..~±j.. ` t~'. S1~tE Of `IfTM elf rot i~ l'.~..~.. iuwe~ C~TIjEN OF WNAT COUNiRt titAR~iED. NEVER wwRR~EO, SUlvIVtNG S?OUSE ~f~ ~eeJe, ~r~e ~ria~s ~+~s~ ~ ~ ~nrntr~) W~OOWEO, D~vO~CED (S~r~il// a. "T(~t-Trri•~ C. ~•A• t0. ~iinnT'~n I1. ~'AT'~l"'>T(~! Tr.'ltinT SOC~AI SEtUl~iT NU~4ER wA5 OECE~SfO EvEt tN U. S. w~MEO ~O[CES~ IYri. ~o. o~ rMborw/ I!I ytt. di~t ur~ or drtn ol ~mictl uiWt lfSIDENCE l20 ~~--Z~-~O1 n 1]e ~~r wME~E OECEASED uStJAI OCCIi?AitON /Girt kiwJ oJ YO1f ~IOMf iIY/1Ij wOII OI 1(INO Of ~USINESS Ot INDUSTRY trvED. IF DEATM OfNRtE~ IN ror4i~j lije. ~rer il ~t~irtJl ~ bT:mT T'rl ~ ~ T'r`T ~ n~ ~ r. '~T'n ~--!v~~ r•r• tN3T.TUf10N GIYE l~o. _ . . t~b. . ~ . n~: RESIDEIiCE t~WRE RES~OENCE-ST~iE COUnTY Ciir, vitl~GE O¦ iOC~iiON u+SiOE C~ir uMitS SitEET ~wD nUM~ER I DM IS11OM. ISperi?r ~a o. wo1 t~a~i~ :~~rs: ~ ~~e ' u`~ i` fATHER--NAME Firsf ,MiIJ/t ` I,y! /+~OTMEt-MAIOEN NA~ME Firrt .1liOJIe Lut Y - . . . , - 1S. n~.r--m• 16. ~ ,r~'•~'A Z INFORMANT-NAME MAIUNG ~QOtESS ~Snrrr o. N./ .U, ro., rir> e. ~i!lr;r, itria :i~I F„ 170. ~ T~ r i 76 l 7 :7l i 1 L- ~ ?ARi DEATH WAS CAUSED BV: :fNiER ONLT ONf CAUSr IEf lINE fOt (a), fbl, AND fcll A/~lOXIMATE INTEtVAI 6fTwEEN N Ei EAiN ~ 16. filt : - Q S ~s, ! :?,:Y fLA ~ ~ u~Ea~rE cwusE ~ai ~ i - ~ OUE i0, OR AS A CONSEQUEHCE OF: _ ~ ':~,'RT W Ce+~ditiou. i/, G - = : ' ' a ~i.~a t... re ~ ~at ~ • . ~~ff DUE TO, Ot AS A CONSEOUFNGE Oi . z rl~ti=t t~i r~rrn v • _ Ifi~s rrrr! !ur fAtT 11. OTME! 51GNIFIUHi CONDITtOHS.Co~di~iorr ao+rl»b+r o iJb b Re rtfatt/!o r.uirt p~~w it jM I/i) AUTOKI li 1ES rtft ~1/J~st qa~iie~r/ Z IY~ ~r N tA Itff?OiRIIj ~IyJf jtrlb 190 19b. fl- ACC~OENi, SUtC1Of, NQM~CIDE, DAiE OF ~N1URY MOUR NOw ~NIURr OCCUltED ~Fllffr 14IlY/f Of UJM?) Jq P.f~f I 0I Oa?1 II, ilt~ 181 , ~ OR UNDEiERM~t~ED /S~~cit~1 ~ ~lowrh, Da~. 1't~+rJ ~ 700. 20e. 10c. 20d. INJURY AT WORK ~IACE OF INIURY .1! 6ost, /~rwr. ih[rf. f.+ctnr~. ?OCATION /CJrttt or K.F.D, wo., tit~ or ti!!r`t. ~lJte. ziOl a 151tri17 7a or +~l e/ft~ b/dR.. dr. IS~rcil)I } CE[TiflUnOn-- .No.~b ll+~ l't.+r .NoNtb D~? Y~.,. wND lwSi S~w MiMIMER i OIO/Gi0 nOi OE~iM OCCURRED At tbe ~l~ts os I1trStC~~k AtrvE O?+ viEw inE 600T (NOUR) Ibt d~re, p1 te ! 1 ATIENDE~ TNE TO .Howtb D~~ 1'rrr AfTER O~I1TH. !bt ~tsf a~ ~1 lwr~ltdst. t !o ]ta. OKEASED iROM 21~. ?~c. ?Id. Zt•. r. r6sr.rufrl~t.rd. GEti~FlUTION-COtONER. O~ rbr 6~~i~ O~ fA[ IlJIIfqJlfO~/ Howr oj dr~~b I br Ja~rJrwt uri p.o~ou~~tJ dt~d ; ol tb~ b4r .+wd; or Ibt i.neitia,.r~ow, i~ wt op~+~~ow. Jr..rb .~IowrG I)~~ 1"rrr Horr ' o~.rntd o~ Jbs d~lr rud dae J~ tbr :~rse~sl if~JtJ. , y 3 I ~20. ~r. s2r. 2 IL- ~ ) ~ - ~ ~ ~ CERiIFlER-MAME /T)~t or pnu) SIGro~T~iR Tirs.sr c: tid: L:.:i ;s:v:::L ]~o- ~)b. ~i 'V~~ hC 21c. I Z l ~ L' j ~ ? ! M/11lING ADORE TIHE! STREET F.O. NO. CIfY OR WLIAGE STATF ZI! na r L i L J ~ ! lURIAL, C[EMATION OAiE NAME OF CfMEiEtY OR C~EMAIORY L AT~ON /(itr, ~ilf+a~, or cnrRl~I ISt.U~1 +~prtif~/ a ,.~arir_1. 2.a12-~0-"f 3 2.~ ver~~ d~ Cere~er•- ~ %~_a1n.TMr2(Zr? C?.; .-P^. i ~ NAME Of EMtAIME! IUC. NO ? _ f~~DIRE O St ATURE ~ ~l C. NO. ~ 1 ~ ='~+11 j_' S' Y:~''' ~s. - .:~t. ^ $ r_-... , t. i ~ fUNElAI illM AND ADDlESS + iSTREEi'NO.~ :C1i ~ • . ~ ~ ' (11t f ?7 r~2"• 7 l •1 t:l. wc ~i i. i -~s DwTE ttEG ~r RE S Si ATUR ATE tEtM~T ISSUED S~GNAiURE OF f_ tj~MG1 DISl. HO. ~e/~-/ ~-73 30. a~ . 1/ ~ ` - o.. • _ ' <f • • y . : ~f ~ •C i . ` ~ ` . ~ ;l. / ~ ~ ~ Z r • _ . , THIS IS A COPY OF THE OFFIGI~I, ~ ~ ,~~~D~AT ~ ~ ` , . - r. ~ t; • . t r THE COLUMBU3 DEPARTMENT OF HF ~ 7~. , - _ . • . ; ; • ~ ~~"~p ~ ~ E i t rt:,C F.dVV~ •,~+f,~/ _ 1 l`ti~.~.~~'- F i . . O~w ~ pCl~'T~`Tn 1p hTCTnrr'm JI~C _ ~ ~ . ~ ~ ~ ~ ~ ~ X~£ - ~ ~ ~ s~ K ~ _ ~#~'~"-a~ * . . . _ . ~_,4:.,.~=~`~F;~;. _