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HomeMy WebLinkAbout2249 ~ ~ MINN'.iS4TA DEPnRTMENT OF HEALTH ~ c~ Seclion o~ Vitel $Uti~tie ~y;~ ~ ~ ; CERTIfICATE OF DEATH _ M' . : . - ~ _ . - - ~ WAu~ Jae~i.d 6vrd U ~mi~iutioe: re+idence befon ~ F~ ~ _ _ - 4. ~~'~~f~IQ~~'iDFNC.E ~ ~s ' t DIAC:E Of DE~fH: S1~tE 0~ MiNNISOU b COUNfY admi~~~onJ ` n~ r _ , ~ coururv Pn~;u3e _ ,t~,~ i~~~nnc~ota._ . ~tA Y ~ LENGTN OF ~(:IiY, VILI~GE OR: fQ7VNSFiIA ~ ~ . . FrCI1Y VlII~GE UR Sc)WNSI'lID Sf~Y m 1 b ~ 8 c~axa I .,~~~].r~,~ood____._.__..--- . l \ t~~PI,^ (OOD Y- tiiu~Er ni~o~ES`s vosr orFicE . . _ d. N~11~E Uf (~I n~~ ~n hmpital or ~m~dubon, 9.e R't<t ~dd~e+~~ 1?~5 Aor land Rd t~ ~ioavir~~ oa h„ P-.~ul J.9 _ . . . _ _ ~usrnur~oN 1277 Dorlnnd Rd 1 ~ i. IS R(`dUEMCE IN~IDE CO~CORn(E UMI151 ~ I. li F1)IUkNCE ON n f ~RM7 _ _ e. IS PI~CE~i U(A(11 INSiUE~CQRDUR~IE U,+AliS> ; ~ ~ . ~ YES q NO ~ j f7 YF$ ILNO YK tl N(.'9(~4:: _ . _W:. / DAIE Nonih D~ Yn~ ~ . . , . : - J~ ~ ~l, ~66 ~ 7 ~N~ME I Df~TN . DCCE~SED ~~pR~,~,LA LINtIELL _ _._....Y._. (Tyoe oi PrMA „-"""-'q; ~~E ~I~nynn ii UP~OER 1 YE~R IF UNDER 41 HRS. ~ ' InlhurMir) J ~ S, SEX b, COIOR OR R~CE 1. MARRIED fQ NEVER M~RRIED ? I e, D~1E Of OIR1H 'h4unthi O~tn Houn I Min, ~ female I«hito I WIOOWCD 0 o~voacEO o Ifovembor 2f~,19~ )7 . ..,__Y--°-----_-_____--_.__-_~._. 14 CITi2fN Of VV11~11~ b T.-.----.--..... 11. 91RfHPLACE (Suu m.lu~<~~~cou~wr) CUUNTRY~ " tO~~USU~I 0(:CUP~I~ON(Gne ~ind4f wor~ 106 INOUS~iRY~USIN~S~ (3p . ~ dona dam~ ~ofl o( waYin9 Ide, nen ~I ratired) I v ~ Iowa U9A Nuree t~todi.cal _ _ ~ ~ - _'"'.I~11. SDOU~ES N~ME v~ . ~j~, F~fHERS N~ME ~.i I 1)b, MOTHER'S M~ID~N N~M~ ~ Q~ ~ John,Lanno~.l ' ~ Alico Chriotain Irwin ~ ~ ~ . - _ _ . . _f~ ~ - _ : U i+~ Ii~ ISOwNSIGNATURf AUURfSS r ~ ~ ~`tS. W~S DfC€~SED EVER IN U~S. ~RMEO iORCES~ ifi 50~ S€C NO ~ E IYet, na, a (II yt~, l~vt wu or d~i~+ ol uniu) I ~ ~ n D~ S' 0,~..~l,r ~ I un~nawn ' : - - ~ ~ no i ?.-18-1~ 18 ,.1.. ' ~ _ iN1ERV~l Of k N ~ g ~ 1B C~U;E U D ~f11( mn o~lr one cwia o« I~na lor (b), i~d (c) ) ONSET AND DE~fH ~ ~ , ; i ~ . ~ , r , . D~Ri I. DE~TH WAS C~USED 8Y: ' ` / ' _ -._.~.._r__.._.._-. I IPA'dfDI~TE C~USE f~) - . _ ~ ~ , ' , . ~ ~ I, ~ 1 ~ Cond~irom, ~f ~nr~ DUE 10 (b) ~ whid 'Nrt nit lo , . . , . ~ ~bae cwtt f~), ~ ~ . miin~ ibe undm i P r z IYin~ auu on Imr ~ _ : = _ _ . ' , (cY _ _ . DUf TO (d _ _ . I - " V(RfORM[D~ ~ PnRi ii,'OiFiEa SiGriifiC~Nt CUNOifi0N5 CONIA~uutir~G f0 UE~ifi eUT Nb1 R[ln~tD fU n~E irnMEDinrE Ui~SE ~~vEN 19 W~S /~U10PSY ~ IN DAA1 1(~) ~ YES;•.^,~,NO U V I = ~a~. onrE oF ootan. ~va. Mei a n ~NC,s c ovEanr~Q , ' ~ r~, 1r emen Of ,1 ~ noN mt~r ~va~.ve ;~~i`~hn , ~ ~ruf~~`L~~.~ncp ~ ~ 1-18 t9~6 m{tra~. ~I.E110 ~la ~ m tra y . - ' i 0 ~ DI5(.RIUf ~ UW ~Uk~QCCURkED ([m~r n~i~r< o~mu~r in Pui I or D~rt II ol nrT 18 ) ` ,A J p0~ ~CCIOENi, SUiUUE OR I I~MI1,iUE, I~DEUtYI p ~ V' ' W ~ . \ ~ ~ pp~ fIME Of How Momh Dw Y~~ ' M V . _ _ _ _ ~ ~ i~f~ N w INIUAY ~ ~ ~ ~ W1-0Lf.~AI~C]~ NCIIRWV~IIIE q~ home~f~m~l~~r~~titra t~aHce bld~,~rK~)~ ~~'~I I:IIY,V'~ll~(iE Uk ft)~IPi',iI,P (()UNTY _ . _ S(~1E . ~ . , . WOAK A1 WORK I . ~ : . ~ a o- u'„~;, i _ _ . , ry5 . _ o E~-?U 1~j66 ~ c i and ihnl I 4+i ~a.v ih~ leernrd a~~ t on 0-• ' Q ~i~~` 21 I cen~ly I ant 1r { t6t decenird Irnn~ 1 ~q ~ry m ` t~ ~n~, ~s~jn I~~6 . n on~l~i1'~~nlf iY~lyd ~he'~t enJ Io tht V,nl nl mr ~n4wl~ I]r IroR 1ht um~i ~tnted ~ eMlibeidei!hxcurr~~le~ . i Y4b. ~UDRF.Si ~''04J(~,~1 ~'1l;Cl~..C~ 'r'7t U~fE ;IG~lFD _ , _ . ~Degite or i~de) ~ ~ ^ ~ 5 'r9~ 5irr,n~uRE ~ ' ~~Ej6 , , {~~,t~ I3a.d~ z ~ ~~~~t~ath at ~ o ~a,~, e ' ~ r ~ ~ ~ t Y~iy,~i.rtLt.~:.~.1,~? . z._ u~, 'f3i rU~l/~L~'~~~'~~ ?lb U~IF ~ V1t. N~ME Of (.IMFIf.kY UR ~~Ch1~lOkY" ~?1J IUI~IIUNI~~H.vllagaorcov~ir) d~air) 0 ,a rcn<I ~~r;nwic~~~,<nY~ i,~~ n~ ~ ~c~l~ A cricin I'~rk b'ondot~ Ifai~;ht~~, ~~~inn ~ Puriol I ~ ~r ~ ;~n i~ ~ nsi;:~~r,F ~.n~ i~, ~,,i,~, ,g ~,~e,~,t ~ ~~1 , I I~~I!i 'dl y'i l. i 7P! ~r ~ 11 '~l I ~:li i ~l ~ i ~ . i ~ ~ i , ~ ~ ~I i : ~ ~ / ' ~~~t ~f , ;fl . . - . ~ _ i 7 •~'s ~ i ~ , , ~?~~ati€~a;aacr~r,~xs51G~a~etx'r~+5~,~R~;~' ' riYak. . ,,.:Tn~s, <