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HomeMy WebLinkAbout0724 - ~ ~E ~?Na RECORO 0 . - E ~ ~ ~ , ~ s CIERK Ci~t"vUlT COURT RFCARD YER!~ICO ,....:~~i. ~i PUPLIC H~ALTH N~r 8 I 4~ PN'~ ~.lg~~,~ c•..1_ t,;:r,r~; ; DIVISI04 ~ 5 Plcatt Rtad . D.dTAIC'P Of COLOMnIA DEPJIR?Mttl'!' O~ PIIDI.ZC HEAL?K c,~nificace 1~iQ ~.=j"•~ ~t: (=t~1 csn~c~?~ o~ D~?rH . . Carefully Bur~Nw TwsNw ! ~n~~Oj2 • 1. 11A1~R Or DLClAiia lint ilillle /w~f L. DA7'S ~te~1A D~y ]'~a ~ fA. Ha~r of Dea1? l7yp~ or Pri~tj OF ' . DSATK . r7 i2em Oi ~II• 7: ltE2C OOLOR OR C6 i YwK blarried. M.r~d. DA OF BIR17I 1. Aff6 (/w re~?. • ~ mationshouldb~ ' W1do~'d~ D"'°'eed: 8pca~r h't 0'rtll~'r) '"'t •p 'n' ~tull7 fuppl~ld. L PI.ACIs OF DEATIi IK W~~glOII. D. C.. f. USUAL RSSIDE.~iCS (IIAen ~ararwt Iiesl. JJ iw~tifWww, r~wlewn whn " \AJ/fi OF HOPPITAL, NUR91N(i HOM6 OR O'fIIER 1N8T1T0110P1 81'ATS b. CO ' TY ~wiMie~) U/ .ot u wtifww.. pN .t.t~rt .1Jna) e. CITY e. 1~SIAS C1TY L1MIT8 ries shauld b~ (SPECiFY Ybs oA xo) p e w r i!!~ n d. STRtJs'T ADDRE3S U! •w.t. r.e lor•tiow) printed in p~s- A $ x ~enc iype blati[ i'+iCAi. OCCUPATlO~ (Cie~ kiwd oJ nork dowc Ib. KIWD OF AUBINEBB OR 11. BiRTHPI.ACB !i CITIZE~i OF WHAT (7DUNTRYt d~vi~~ wwt oJ rorku~ tiJs, seew i1 ret"ud) IIiDU81'RY (Siate or Jorryw coatr~r) lis. F~TIIER'3 NAaifi 1~. ~IOTHfiR3 MAIDS.\ DIAdf6 11. NA]1E OF SLH~IYIKf3 SPOUSS - ~ t cerli5cal~ bf- ~g, ~r~r in U. 9. 1~. 80ClAL SHCURITY ICO. l1a. 1NFORD~tA~I'1' RBL ~ftUY3JIIP TO DBCSA3BD lTb. ADDR~ Sireet Citr tt e plTI1DaIIlIIZ Armed Fo i :l tecoid w~l1 18. CAOSL O! DLlC[H: (S~ta oa1~ owr nrae ~er liwc lur (A). ui (e)• ~ leterrd Hetwes Oaat ~;er:y execu!!d, pART I. DF.ATH WAti CAUSfiD BY: ~~~~5~ • I!1lffiDIATE CAIISE Uremi a t ~ 1 Cowditiowa, i/ ~wy, 1 9 ~~J . rhicA DUS'PO (b) Carci noma of the bl adder ~bo~t caws ~f~t- I ~~r~ L~ ~ubmi! a U~ nc~ rwdairuy ~.r.s -;icn:e of Dea1h 'l, l°'~. I - i'.e Departraen! DUS TO (e Pu51i: j~eall2l r pART II. 07`~IER S1dNIFICANT C~ONDIT10~I3: rnutriF,utio~ to dc~th but ~M lf~. AlT['OP9Y~ l~b. It1.s,~leteFiediopCoaridend nlated to t6e te~miad di~eass oo~ditioa ~iren ie put 1(~) YBS OR NO in Ueterw~o~ C~uw ot Deat6. ''..n 13 hct~:s a~- w ~S ~ M IF OPERATIO~i V1A3 PERFORafED l0~. DATE OF OPERA?IO~i llb. OOrDITiO~i FOR KHICH OP~RAT10\ c! the laws a~'V~~pl.h"tE ITE]13 70~ ~nd 20b NAS PSRFORl1hD ':'.s Di~tric! of W T~;3, U=~~- ct~~~r ~f ~eriJmt, wicide, hm;- tlb. HOUR AND D?TE OF I~iJL'R1 :]Son1A, Dar, Yeu lle. DE.SCRIBS HO\Y l\1CRY O(.`CURRED a crle, or wnoec uodetennion! M (6wtcr wotrm oJ /wjw~r iw Avt ! o~ Ihrt 11) V 21~1. I~TJIiRY AT WORK: 21~. PI.\CR OF I~IJt.`RY- fAf Xuwr, Y~rw, F~tforyr. lII. I.OCA1'10~1 CIl'l' ('()l'~fTY STATE :i.A Q ('~p~r~jy y~~ ur Yu) 8trcct o? U~c Hrilduy, IIIr.) :ss ouT ~ Zzxx~Y~lc x~7fn~li~io~cxa~pl~L7cr.lfa.y u. a.~.o..a Ira. --------~'2__:_~. u=r?-0-• a--= ~"23-----• u~Q_, tla Op c..) IeN F• ~~THI$ snw th~ d~c~oa~d ali~~ os It--- °~d a°}!dJo~- xe+!l[~9~•~?.!~~~ oa /1~ doN \ev sWt~d oboh. t~~sp~TaL•• _._~-23~---•• ~ . - 92a. SIGt1A7 ~11E ` • y:;••~ '=?~~~`ri:•. - ?M,. I~ATFi FIRNkI) ~ ~V"~ \ - ~V \ ~ l rI/ ) ~ ~~~~1~!1.• '~.]1~~~~:~.~~ N~~~:i. 'J J • ~C~ ~~~.:a ot fh~ n~ ruti•,u'IA~1•s ,,~*:~;:~~::_.=r ~r"~;finn}~~e . punishabl~ ~ xAa~t ~~ry~~ GRACE H. GUIN~ M.D. _ '-f~;• `r.e sr imptltOn• C ~ _ - t3~. HI'111~i. ll~b. DATF: l7r. ~i:\~1E O} CF:\1}7~R~'~.CA ~O~tl' t7J.~ IACA~OY (Cify. (~,rn, or cvrwlY) (Sl~ft) ~cl~'' ItEatU~A1~Y ~ 3 30 70 Aaltimore N A1:~ 7f'e tdcl r~. F~:.}:~~.v, noa~F: Nal ey ~ s Funeral Home ~uxnr~+~:;. sry -~fATUItF: :3.~.. c.nt:~~~rAKF:~e•x ,;p ~c?x:i.r~t~m~tw 2-C~G .~i?t?~~F:~, TC1C, Mt.Rai ni er Md ' :~:1r!~ ' ~ ~ ~ran,t:ic ' ~ , , • ' j~'?' . u i . . - ~ .3~~~ ~T~ f ~ 1tF:\fA1tK~: •~•~`;~•~Ea _ - ~ ' - i ' - r 't; i~~r ' - . ` ; ~r' / ' : N.'1 S " . _ G t-~._:- . !SM ~ ^ , ~ . L:...r. ` ~~~w ~~~~r w ( i i,.'i~' ai~/l)1/l' 1-`. ~i t,r...t` •Sil~l l'(/~•~•(•('f, 1'l'~~1'l~lf!ll~~. l t.`~ U. ~.•.t' I ll~l ~ c~~t•!; i f i~~, • ( i I c~~.! i!~ ur.i~~r' ~J i t:Il i,ii~~ V i t.~ ! i~c~ui•.i~: l~ i~• i: i«t},- i r.t c~i ~ GO= ~ . i , ~.:I~~.1llt'!1t', O~ I~l1I) I I }iC~{ ~ T.~:. A . ~ , ~ I • , , V R f`•l'iitl ~ . ~~..~~~.t ~ ~ ~ ~,il 1 t, i~ j BOOK2~ / PACE_ I I . Zt~~" V;i.L i i~ . ~ f 1 tiE~1L 'i i r.•_, ~ . ' „c,~~: k~.:.~ - - - - - - - - - - i - 8 i ~ ^~7 ~ `,.w:-~3. I,~i _ -