HomeMy WebLinkAbout1568 roRU N0. vs~7 STATE HUNG ~ATE i
IOOM-REV.•1~ ~ ~ =
STATE OF WISCONSIN 2~A~r•~~
~EPARiMENT OF HEAL~H ANO SOCIAI SERVICES SiATE DEATN NO. ~
' OIVISiON OF HEAITH
IOCAI FIIE NU.ti18ER ORIGINAL CERTIFICATE OF DEATH .
;.rrr DECEASEO-NA.ME ~~n~ AAdNe lOSI SfX DATE Oi OEAiH ' MonM Ooy ~eer
ROB_'~?T ~f I•I1D?"IG ld Au v 1
R/?CE- wA,~e. Neyro, Ameacmin,tan.EU A~e lost S~r~AOnl Under One Yeor IM~der O~e Oa~ OATE M~M Oo1l Ysor C011Ntt Of DEATH
~ u'h ~ te Y`°'~ 55 M~ o~ri M~~~ ~ s~RTM APr~I 7 1919 oaauhee
a. (~~hl~5o. Sb. Sc. 6. 7a
p NA~~F
OF C~TY. V?tIRGE (If N~itAer, Nane Tornship) Insidt Cify ot NOSPITAI OR OTHER tNST1iUT10N-NAME
w llecotion of OtatA) Vill lwn;ri (I! Npf in Either Gnt Strtef oM Nun~lr K loce/iee)
W m Port Wash~ngton ,~~rK ?ra ,a. St A1 honsr,cs Hos ~tal
" ~~~~~d I7 Neve~ Mwritd SURVIVIliG StOUSE t~i w.~.. e~.~ Mo.aM r+~~
STAif Oi lIRiH pTtZEN ol WAot Coun~ry
o:~+ ~ ~.s ~.,N«M c«~~~.~ Ame1 ~a l)amich
s. A~eto YOi'k . 9. U s ~o. O w~~a O~~ ~i.
SO(~AL SECURITY NO- USttAI OCCUPATIpN Gi+re Kind ol Wak Ouriny Most ol Werk~~y Gfe KIND Or lUSINESS OR INDUSTRY
Consul tant „b. Plastic En ine~r n
14. 0~''T~j¢''~'42~ Eren if Re6red
:"!h REStGENCE: ~STA1E COl{NTY NMI1E OF C1T1?, VItIAGE . ~ ~~s~de Cihr a M.AIUNC ApORESS-(HowN Addnst a1 Time ~f Oeo1A)
• Ilf HtitAll. Nan1e To+nShp) YillOq! lim~b -
,.,FI orida_ „~.Jeresen Baach o o~ ,k.Yenture Out 60
FAfHER-N4ME F~nt M~ddte lost IiAJTHER-MA1pEN t1AME Nat AI1i0dle ' lost
Bea trf ce ~f~Ils
_ Theodore zua~i ,a
~ iNFOkMMIWi-NAME ~AA~t1NG ADDRESS S~reef a R.F.O_ Na Gb a Villoge Stote 2~p WAS ~E(EASEO EVER IN U.S. AR.uEO fORCES3
° Amel ~t a L udra~ ~,e. 2 2~ E. R ~ ve r Rd Gr to r~Yis n~. o;;K re Wa or 0otn OF Strv:a)
e: v u 17a. ~ C tnown
- 18. PART 1 pEATH WAS CAUSEO !Y - E Only C e li Fot le)~~ ~ Ou?~PMn _
Co~d~t~ons. 11 My, A Immediofe Covse: ~ ~
N'A~cA Wre R~s~ fo ~ « ~•o
N Immed~ote Cwu Q. Ca~sea~ence o(_ ~ 7 ~
,.-~--""'"'1~ Srotcng fF~e U~der- t
?y:ay tane tus~. oae ro. w os o ~
t. eonseouenc~ of: r
- PART 11 OTMER S~GN~FICANT CONO~TIONS: ond~t:ons Confr~butwg to Deoth oui not Rebted fo Couse AUTOPSY (Specifr) MNi AYfO~fr llN~alOS ODNf/0f~
• . G~•en ~n Pwt I (~?f 190. ~ Ya ? No ~Q
~
~
~ ACC~OENT OATE OF Monfh Doy Vew Nout HOW INIURY OCCURRED (Enter NoWre of Injury :n Md 1 ot POrt II, Nem la
. 2 Z [1 SU~GDF INIURY ~
' 0 200. ? NOMKIOE 4tx. 2od-
i? INJURY AT WO~1C PlA(E OF INiURY fMome. Fwin, Slreet, Fxfory, Ett.I IOCATtON Slreet or R.F.D_ No. Ciff o? Villogt Slott Zip
t~. p Yes p No ~ (30K~h) 209_
CERTIf1UTtON-/~t-0ntA Doy Ytor Ma+~h pey Yeor AqG t¢ST SAW HIMllIER ALIVE ON DID YOU YIEW iNE ~EATH OCCUIlREO At iht Vtoce, on ?At
?HTSICIIW Mwuh Oor ~eot ~90Y AFTER OEATM (liovrj Dae, a~d. To The.les~
1 Anended Tha ~ ~ To 01 Mr ~no..ledge. Oue'
~1 . To Tnc Covse(s) Staee
Deceosedima ~ Zlb. 41t 21d. °Ya yle.~~ 1~l
p CERi~f'UTIpN-eRFD~CAI E7IMA'NER OR ORORER~ Un TAe Bosis of i1x NWR Of OEATM THE OECEOENi WAS PAONW?ICEO OEAD -
Eran natwn oI TAe dod~ oMfor TAe In~estiqot~on. In M? pp~nion. ~eoM Mont y Yer ~
` Ocwrttd on TAe Oote ond Oue To The Couse(s) S~oted. ~ ~ +r
~ 22a ~ M. ?26.
~ CERi1FlER-NAMf (ipye or P~inq SIGNAtURE-CERTIFlER Title OATE S1GNE0 1NOO h DoY Yeot
i v z3o~L~(
~.~10 M'~`~-~~Z ~ r.~e. zx. ~J
E ~ptUNG AOWtESS-(ERTIFIER ~Street or .F.O. No. C71y er ~ '
. z~. 3 a~ V~ -~~K-~(Lc ~ ~6 -~'t i1~s ~~v~ a,,,` ~o~w t Sc S1'sci"
lURIAI CEMfTERY OA CREMAiORY-NAME~ ombmen t IOCATION C~f~ Sfate
~(REMAT161! ~4?oodlaum Cemetery New Yor~ N.Y.
~ 2H. ~ REMOVAI 2~b. 21c.
~ BURlAL-~ATf luonih OoY Yew fU~ERAI NOME-NALIE AMO AOpQESS ' Sireel or R.F.p. No. Cily or Vit~oqe Stofe 2ip
m z,~ Aug 9 74 250. L~icel.ler F A 979-Z2th Ave Grafton Wis ,53024
FUNERAI OIRECTOR-SIGNATURE REGISTRAR-S~ ~ ~ ~ OATE RECEIVEC tr locol Rraistror
W~~.~t..f.~,~.~ 1~1~.1.tJ F~1 Y~T' ~a}th Gor - reo.
• ~ : r ~
~s~. z~.
- - _ . ~ _ . fttED~r4f~Q RfCORDfO - -
( ST? iE OF WISCU*ISIN~ _ ST ROCc PO TRAS `A
SS CIERK Ct:tCtllT COURT- ~
(COUNTY OF ,~`LAUKE~ ) ~RECORD VERFFIEO...~.....
Nor - 8 12 i4 N- ~~I
I~. WILLIA~~1 ti. ROCK, Regi3tex~ of Deeds, in and for said County~ ~.~d-
~ do rereby certify that t:~e annexed is a true and cor:ect transcript ~
fron the records in my office, as recorded in Volum~ 32 of
~ Deaths , on page 358 ; that I have carefully - .
~ co-~p~red th~ s~e .+i~r said Records and that it is a cor:act cv_;~r _ •
~Zereof ~ and of tne wi:ole thereof.
~ , ~i ~ne .s ~y rar.~ 3n3 offici3; saaZ at Yort k'ashin~+on, t: y~ 12th
~ay of Augus t ~ A. D. , 19?4
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- REG~ST:.k GF D~'.EDS
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- . . ~ . . AEPi1TY
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~ ~ a~~K 2~33 ~A~,~ 154i6 ~ ~
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