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HomeMy WebLinkAbout1766 . . 2 i ~tifi i - - ' ; , F LED ~ • '~E~ ~ CI'IT Or ~L~V~:i_Atit~ HRICNTS .erscla!! Tal.erlc! lltl. ~!A lscrlbl t~etNf~~. ~VC t f LA. •s . • ~ = '~:1r f. ~y;,~,~,,, ••~~~n. 1[erie~rnr ef Re~ QG:'t:ti, . , ~ . -~ai Is 1 <r_a ~b~ ~..cor1! e! ~h?• ottie~ aa:. aoc ~ . : , . ~ . ~ mr a~^.e `CtERK : i:~RT - ~ ,.r edt~:~.~_ .:e:,.r a-~ ,.t:~. ,c: . . ~_._r r~• RECORQ V ~ , ;•.:.t . ~;-ou ~ _~.~~-`"r"1 , ~11.~t1.~.~;,. K.;.~,~~.~.~...: AeR 1~ i 3 AN ' : . ~ ~ . _ ~ 2: ~3ti~5 ' ' ' - . ~ _ 1...._• . . ~ • ~ . •;;~,~HO3 OHiO DEPARTMENT OF HEALTH HO'~ DIVISION OF VITAL STATISTIGS s"" N'' lti~at~•is~. D:x. No. Rc~ixni~ l~io- ~ CERT ICATE OF DEATH • OEGEASED-NA Fi .NiQll~ t DATEoO~~EAT~Fi~~. a7. 1'~u~ ~ L • ~jAG R'b r rtt e, ~rtrirt~ AGE- !ru Ut~DE! 1 1f~! UNDER 1 OAt OATE O{IRTH l.Nertb, D.p, C~ TY OF ATH ~ r~/iw ~ ~c Iristb +~a) .~Isi. D+lr Heor .Ni~. Yeo e • ~ ~ ~o. 3a. Sb. Sc. 6. ~ ~ d E. R tOCA OEA7M INSIOE GITY IIMITS NOS/~iAl OR OTME i1TYT~ON-rJAME fl/ J ifb jirt ihtt d wrsM! lSleti ~rs ~r w~1 Tc. ~d. ~ STATf OF li wet i~ US..1., rt CITIZEN OF COUNiR1f t~lE NEVE~ MA~l~E , • i fl/ ~I~. f~ J s~atryl • C WI D v lCEO f ttil)) V. V • 1 li SOCIAI SECURtt UryEt W~?S OECE ED EVER IH U. S. ARM FOlCESi f Yri. ¦ . r~4s~~cs1 Il/ 7~+, l+~ w? M Ltn renictl {ISUAI lESIDENCE 12a. ~ IZb_ WMElE OKEASED ~Al OCCU?At~ON lGiee ~i uo de+k dr ort / ~ [IND OR INOUST L1YE0. If GEATH ~yr4iss /i/~. en~ iJ ' • OCCURRED IN INSI1TUTtON. ~'i1vE 1~. . =AE~~~f~~EfORE tES10 E i~iE C ~AGE l TI ~ 1 IDE pTr UMItS SitEET ANO NUM~ ! fSletsll fa or a1 ~ / ' ~te. 1 ~ c ~~e_ u ~I fAT11ER-JiAMf vnf ' JIt Lu! MOT~Et-AUIDEH F+nl ~ •~~f ~t ~ ' ! ~ !3. 16- ~ ~ A T AME. Mw~uNG woDtESS ~Sne~r ~?1K '.U o~u or ~ r, u.u~. ' 1 t ~ 7e • 7~` f 17•. ' ~ . a?tt i. DEATH WAS CAUSED BY: (ENfE[ ONlt/ OHE GUfE fft LINE fOt (d, (b/, ANO (dl A?~IiOX1~tAiE ~nTERyEATl+ ki ` ` ~i~u~ u?use • • C~C.~'`'`o."'"i .3 i~aw~.a ~ DYE TO. O[ AS A C~HSFQUENCE Of. ~ ~ CnJiN~u. i/ ~a7. ~ o~ls~ s~~t ris~ t• bl d ia~di~t~ tswt I~). if~flss l4• arwi~?- WE TO, OR AS A COHSEOUENCE Of. Z hi~s uau~ lirf y„ ~Atj 11. OTXEt SIGNIf1G1NT CONDITtONSCeslita+a to~urii~rtiss t~ 1e~tb ~rf +wt r~/u~l r~u~ p~ iw ~e?t 1(~1 ~~311 IF TES rere fiwlisp ts+rilr?:~ i (Ya ~r y iw /stna~i+w~ c~rrs o/ leab ~ ~,t (,~.i ~v ~t.'r. p,.ti L~.t i, t'f ~t.d.,l.t~ L ~ ~in ~ V`Q.a-G ~iut ~et ~v.. ~vs. ~3. ACCIDENT. SUIGDE. HO~?ICIDE OATE Of ~nIUR~ MOY MOW INIURT OCWIl~ (Ewtn +wrsrt ~J iwjra~ is ?of /~r ~ol Il, ittw 181 Ot YNGETEWINEO IS,eri/~) I.~le~ti. D~), Yes) ~ lp,~ 200. ZOc_ tOd. ~ INIYRY AT WOdC ?I/?CE Of IN/UR~ At bo:t, /~s~, ur~tf, /~tt~?~, IOCAi10N /Sher1 R.F.D. ay /ifl~i~. if~tt. u11 Kt ISN~+1f 7ef ~e1 o~s~ Nlj.. ~tr. IS?~ri1~1 ~ p~_ N CERTIf1GTlOli- .~lowtb D.~ Y'ta .N~wllr Dq 1 to ANO IAST SAW MIM/MER I DID/OIO NOi OEATM OCCURREO Af fbt ~//tt~ o• ?MYSICIAN_ Al1YE ON YIEW TME WO~ (MOUt) ~ t~t J~df. Iss, 1 ATiENGEO iME ` TO 1W~ti D~ m AfTER D TM. tie • ~f l~A-.~~-'I~/ P 4..~.r.ls.. < <o 2t~. OKEASEO FROM ' I Z1A. J~^^ Zlc.'Q 2T 73 tl~. ((;J 21~. l? M. fitt~+rrtf~l it~ts/. ' CERTIf1GT10N-COROnER: O~ tbs b.uis o/ tbr asrai io+~ Herr le~/b T1~ ltrtltu a-a~ ~ro~~~~ /~d Y~ ~.w ~ ~ . ~ e/ ~ie ~od~ wd/or ~bt i~rtuiptiew. iw ~r ~?iwio~, /~itb , ~ a1 ~;r ~~nrr~~,/ tbr Iu~ ~sl [rs ~o t~ s~rs~fil rarrl. ,t.y ) 3 !e ~ n.. ~i?. / C' ir. ~ CEtTiflE E fT)~t I~i~[1 SIGNATU ~ ~ ' Dfpt~ M fitlt DATE SIGNED ~ ~ ~ r~.. ~ JI.IN G- 4 (1. ~36. \ ' 1: L~ l~ ' »<<~ ~ 14AlLING AODRESS-CfRfIf~ER ~ p SilEET OR R.f O. NO. yGTT Ot YIIIAGE STATE ZII l ~ 1( ~ . ~!~l: 1 ~C~ . ~'1-u~-t~ f ~.r d ~~l ~t..r ~4'~ ~ I _ ~ ~ l, CRE(~tA OH DI~iE H Oi CE/+~FJERr CREuATO Y LOGT • I it~ rr/! . r rorst f~tt) • ~ ~ • ~ 2~A. ~ Ie I!b ~ . NAME EM~AIMER • 1lIC. NO.1 iUN~M.~I CTOR'S 51G (LIG NO.) i • e~c 23 ~ `o /U fIRNI ANO AO R' SitEET NO.s . (G ~ (S 1` 1=1?1 • M ~ AfE REC'D tV REGISiRAt'S SIGNATUtE OAiE tEtMlf ISSYEO S~ NAiYlf Of fERSON ISSU NG IERMIT DIfT. HO. IOGI tEG ' ' 18~:'~ „ _ _ ~ ~ " ~ ~a. /o -a~-~3 _ . 4~ 225 ~~~i?63 - - _ _ . r _ _ _ ~ - ~ . ~~~-~fi~ _ < v~~ s - ~ ~ _ . a. _ a-~;~1. _ ~ -