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HomeMy WebLinkAbout2541 A ~ ~ i ~ ' ~89~64 ~ ; CITY OF NEW GRLEANS CITY `~~~~1~~ ~ l,1+Y' e~RTH STATE OF LOUISIANA p~~E w~- CERTIFICATE OF DEAT~i ''1O~ ~ U!T NAME-0iBECEASEO 1~,/ i~111ST M)AME 1C. /S~ECOtiO N~ME 2A. MOtiAiN DAY vCww Z~. NrynJR • , ,J~eVGVJ / - l~IU .O`~Q~ OEATN ` I 1 I I~ ~{7I VQIJI • l. -ii L .i SE}-MwLE OR FENALE COLOR ON/ RACE S•MG(IitG lVC~ MOff1[d S• SUIIVIVIf:6 SPOUSE ~ , ~V/a~Q VY~Wl.Q ~ ~~Ilf 1NIi Oi~CVA~~GVEG/VJ ` W~OWI'd ~ ~iYOICC'd ~ r ~~y . DAT[ OF 611~TN =CEASE~wGE OF DEtEASED u~o[w ta wo~~s A. STATE Of B~:~TH Ur t~OT ~q w. G~T~2EN Oi WMAT COUN7A• ~ r~ ~ ~ ~ • ~ ~ 1~5 MC~]Nt - OA MOV115' MiN ~~4NT11r1 r~ v ~ l~hode .Q.~.~and J~ (,1.~ t~ ~p,. USUAL OCCU?AT10N ~G~rt KINDCi wO~K CoHC Duq.nG 10~. KIND Oi OUSINE55 OR INDU57RV ~11. SOCIAL SSGURIT• NUM~E11 fT Oi WOA1l~~l~ IITC. CrEM 1i A[TIwEO) 1~ot.v~e~v.t e. p 1jA.CITt'. TOWN. OR IOCATION OF DEATM 12~. PARISN OF DEA7H NEW ORLEANS ORLEANS ? 1jt. NAME Oi NOSrITAL OR II~STITUTION 1ti r:OT 1N NOS?~TAL OA 1YSTITU/10N G~~C S711EET ADD11E~f 011 IOCAT10N1 30. ~S ?LwCE OF OEATM INSIDE ' uTV uwiTSr ; - Tocur.o .~r~ .i~r.n . 1 Y~ ~ ~ a ~t GtTY OR TOWN 1J~. ~AR15M 1~C. BTATE ~ S~CIQ/t.t li1Q/Lf.t.lZ ~.~0/1,(.f,~li ,y, ..i 1p. f:REET A/D~ORESS--~~s IIYRw~ p~yt Lq~T10N~ 1~[. If REfIDENGE INSID[ / ~~~~/~-0~ LQJ~LP... ~ . ~ ' CITY IIMiYK ~ ~O ~ t - 4. fATMER"S IAfT f1UiT M1DKt 1 . MOtHER'S l4fT ilAfT M~DOLt ~ /P NAM[ MAIDEN lh o~rmacjt Ne.L~on N~ME ~nman Dozi~ ! Ctfllfy TIW1 1IlC ObCVe St01le ~GNAT E OF INFORM4NT ~6~. DATE Of 81GNATURE informot:on ii true ond cOtrect ~ ~ / 1, , To fhe test of my knc..ledye. i(.ai~. f ...c.... . vART I. OEATH WAS CAUSED !Y [MT[A OML~ OME Cnui! ~E11 L1NE fOR IA~ AND IC~ ~~~~i~ti~p~u~ ~~s Ct~» f7. . Nca~4rc uus ,I ~ ~ ~a~ - ~T~PR G'fieE' ~A ~ ~c~/jI a~.F',t/ /1 ~ E ot ' { ~s'~ ~ ~OUE TO. OR AS A CONSEOUENCE OF ~ rAKh 90V! fii! 10 ~ ~o~. CF.e~~,~.~ ~/~~~~1.4.e ~'~dr~.~',~~ ~,af.,~ t~ ~„d~.h~- te~ ~~X DUE TO. OR AS A CONSEOUEMCE OF ~ ~ ~ART II_ OTNEN 51GNIFtCANT COHDIt10N5. COMO~TIONt tONT111~YT1NC TO DtaTM •UT NCT 11[IATFD i0 CwViE ~~A~ ~ui0is~ ~'~s GIVEN IN IA~T 1 IA) ww0 ~Sf c4wf~M~lO ~ ~ D[~[~Y:M~VG - 1~lS[~i NOQ cauu or ou*w• vn ^ f~e n 194. ACtI~ENT fU1C/DE NOMIUOE 19~. DESCRIaE NOW IN~UR11 OCCURIIEO 1[MTER MA7u~C Oi ~MJV11T IN M/1T 1 OR MwT n oL IT[M n./ ? ? ? ~ 9C. T1ME Of INJUAI/ ~6J• rONTM DA• ?E/1• ~~~~~'S yi FICL ~ F1 :R~J~ O11~ ~.~i'~V M. • 1YO. iNJUNY OCCYRwEO l~t. PIwCE OF ~NJURY w7 Nowt. iwwY, 1lI. C Y, TOW O ATION rww~ srAit tirH:lE AT 0 tvpT Wl-tllE fTAECT. F/~CTO~~. Cii~C[ ~LDG .[TC K'ORK AT WdRK ~ ~s?cc~rn ~ . y 20. 1 CERTIfY TM~.T 1 ATTENDEO TME «yd thpt dlOTh OCCUftlG =~A. A OF PMY ICIA ~ 21~. DAT OF N•TYRE ~ OECE• D pl1 'i~t dOt! Or1d F1011f ~ ~ ~Y To~ ~ o~,~. J~,O ~ - :,o,,, ~ 1211. ~~p _ awTC 1MtwEOS 2i. MwM£ AhqD~LO~CATgION OF 7. 1g~~ Dlliis~l! DIRECT ' Gemation... ~j/~ J/7 ~'~`.°1 O/Ut~~A ~ /LPJIfQ.~O ~B~UM~~~i~n ~ ~ 1 ~ • ~ Removoi. . . _ . -T ! ~ ~YRIAL ?11AMSIT rERNIT NUM~EN 25. AR:SM OF ~SSUE 2f. DATE OF ISSUE IG TY E L AL RE 1 AP ~ P'r~ 1 r 1974 ~ - - -~1' OF NEW ORLEANS, Bureou of Vitai Stotlsrics a+ cooperation with the tQuisiprq.St e oeQwtment of HeoMn ~ ~f . ~ ~umArr.+ yw~~i •.^?S,'-.-~.;",. S c~~pCO ~ . ~ ~ j~. , ~~11,` ' t-- ~ V7 a_ ~ ~ ~ f~ I CFRTIFY TN~l7 T~t~ ABL~t?~ IS A TRt1E M?~ CORRcCT~~ ° ~ flIlty ~GIST~R~~ tdITN TN~ H Vtg1 f1~it ~ ~~NTENA~ ~ ° ° ~ ^ ~ L. .S.R.S.~I., VI ~ ~ ANU IU~[1LIlTORy PA7TENT SERVIC~S B[lR~Atl ~F ;~I~~~STJITIS T ~~~o . ~ _ ~ : ~.:;r ~ °c ~n+ ~ - - - ; y 7C iv ~ " • G~~ . ~~`~r ~ ~ , . ' o. - - ~ ~ y ~ . L r ~ S~A REGISTRAR , J UL 3 0 ~974 ~ ~ o R . . . . _ 289~6~ ~ 6~~K 230 PACf2540 - . - - - - - _ - - ~ ~h~~~: _ ~ _ ;It ~ : - v s. . y; _