HomeMy WebLinkAbout0878 FO~M M0. VS•1y STATE fIIING OATE
~OWM•lEV
STATE OF WISCONSIN
`J OEPARTMENT OF HEAITH ANO SOCIAt SERVICES
DIVISION Of HEAIiH , STATE OfA1H NO.
~oc~~ FaE NuMaEa ORIGiNAL CERTIFICATE OF DEATH
' OECfASEO-NAME ~~n? M~d01e losl SEX OATE 0~ DEATN MonM ~oy 11eor
Daniel H. Berrong Mala November 5. 1974
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R~(~ E-
Wn~~e,
Neqro. A~nentontna~m.Etc ~qe las~ l~rthdoy UM~r O*e 11eor U~wa O~e Dor DATf Mon1A Oey , Yeot (p~?NTY OF pEATN
~ lfeors -~µo„~bs Oars Noun M.nuta OF ~IRM
White ~soec~~ri so. 55 se. x. e. December 11 1918 ~o. Milwaukee
~
!p HnME Oi C~ir, vittaGE pf Ne~~Aet, Nan~ tov.nsh~p) ~ns~de C~~ror MOS?tTAI OR OTNER INSTITUTION-NAME
' W ltxohon ol Deo~~l YJloqe l.mits (~f Not ie E~tAer Gne Strett ond Humber er lOtotan)
i< ,b_ Ziilwaukes 2~rK p~a ~a. Col~nbia Hospital
STAIE Of OIRiN ' Uit2EN of WAof Cow~try ~~rNed ~'j Never MwnN w~VIVING SPOiISE 111 W~le. G~ve Meden Npne)
G I tl Npt m U N t Country~
I~ e. Il l~no~s v. USA ,o_ o w~,.~e ? o,,,««a Janet want~ ~errong
~ S~iAI SECURiT11 N0. USUAI OCCUPATIOH G~rt K~nd ol WOrk Dv~~nq Mosl of WorY~nq l~}e KIkD Oi SUSIIiESS OR INDUSTRY
E` `r R"`"° etiil Food Store Chaia
~~~z. 397-03-0034 u~u ervisor of Delicatessens »~R
~ RES~DENCE. SiATE ,COUNTI/ NASAE Of (ITY, VIIIAGE ~~t~de Cny o~ MAIUNG AppRESS (MOmt Addrat ot i~me of peofA)
~11 Ne+tAet. Nane TownyMp) YJIO9e Lundi
~~',-b.t'7~-is-consin ,.~lSilwaukee ,.~Whitefish Ba „~.~rKo~ 4634 N. Idlewild Ave.
FAii NER-NU1AE F~nt M~ddl~ last MJTMER-WA~DEN NAME F~n1 M~ddle Losf
r~~ S~oauel B. Berrong 16 Elaie Anderson
W i * ~
~Q i i~f~R.MANT-NI15~E MAILING AppRESS Street or R.F 0. No. Gtr or Y~Ilcqe Stote 1~p WAS UECEASEO EVER IN U S AaMED FQRCES?
d~ ,~F res, G,re Wor or Dates o1 Serv~cel
~,,;Mrs. Janet Berroag „b4634 N. Idlewild Ave., ~dhitefish Ba ~rK G~ ~ U~kno+n ~ n
J~ - 53217 0~? ar~o~
,~B ?ART i O~AfN WAS CAUS[+~ dY - E~~a O~ly Crte Cause ?er line FOr IA), 16). a+d fC) {~iS(~.~
i i1 r
~ ~:ond~~.ons. if An~. A. ~mened~ote Cwse: C( ~L ~_1~±~.y+,:~41 rLii ~ ~l
I YIiA~tA Gore R~st 10 t0. or CS o ? •1
immed~o+e Cou:e 8 Co~seeve~ce oI_ [ t ~ ~ ? ~
--'`^I Stoueq tAe Under-
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<i 1n~9 Couse lest. ~(...'~'1~• ~ . _,-j~. ~ , , ~
~i Oue to, or m o i, c I~
~ i C. Co~:reue~ce of: v i. l~J ~U1.2 1:f r ~ JL' ' C C~~~t.~ e4y 7~! Il _ ri.:; ~..f
~ VART ll OTNER SIGNtiI NT CO~DIiION ~ CO~dd~Ons Conth~ufinq to DtotA Out not ~tlntt fo Covte AUTOPSY (SpKifY) MtffE AYfO/f1 iM10N~laf CONf~OI~
G.re~ .n Porl i(A) ~ 1 ~y~ M Y~TItWMINO CAYfE Oi OEAiN7
~ :T J~~_ "«'YJ • 190. 1%. ?r-YK ~ No
~ ~ A(CIOENT DATE QF ntA Ooy Yeo~ Hou~ MOW iN1U~V OCCUNREO (E~ra Haiure of In~ury m Part 1 0~ Purt 11, Item 181 -
Q SUIUDE IN1URr M-
'Wp~20u. ? HOM~(IGE 2Uc. IOd
-,v~ INIURY AT WORK VlA(E Of INIURY ;ltome, Ferm, Streel, foctory, Etc.) LOC~1i0N S~~cet or R.f.D. No. Gty w VJlogt Stote Z~D
V'
't~ ~ p va ~ no ~or ~soK+~r) a0g •
~CERTIfI(ATION-.MOmh Doy Yeot Mo~th pa~ Veo~ AND I~ST SAW MiM l~PR ALIVE ON D~D YOU ViEW ~ME DEATH OCCURREO Af The p~oct, on TAt
--1 PHTSICIAN Ma+~A Da~ Ttor - d~0~ Af1ER OEAiN ~Hpvr) Date. md. To iAe Betf
1 Attt~dM The ~y,[` ~ ~ SvTo ~ f J4 n y wv io TAe Couse s9St cee
i Oeceosed fran ~ ~ I~ ~(rJ ~ ~ il! ~ Q `~j ~ } `7 YK ~1'~ 12 = is +
i=; Zta 21b. 21c?/i 21d. 21e Nfy
'iRi irUT!ON vEJ~UI ExaM•hER QR COROHER: 0~ ine Eosa o1 ihe HQUR OF DEaTN tHE DE'EDENT WAS PRONOUNCEO OEAD
E.c~++not~on oi The Bcdr ~^0 or inc ~n~esr+po~~pn, Mr Op.n~on. OeotA µp~th poy Y~pr Mour .
Occurred on 7Ae Oete aM Ove To iAe (ousr,s; Sreeed.
~ - /1 A?. M.
CERTIFIE~-HAME (Typeor inot) SiGNATUAE t T~tte DA~E SIGNED Monrh Day Yeor
{ ~~~~}r~ / ~
€ i~i ~30. A. A.-Moibroak ~~D• z~e 'L K•~{, 2~c- ~ 1~ - _
E i 1~~!I~NG ADOQESS-CERTafiER S~ree~ or R F 0 No 1 C~h o V~t~ Srou Z~D
;
~ ~'~,d_ 425 E. Wisconsip Ave. Milwaukee Wisconsin 53202
~ _ f !~lURIAI CfMETERII OR LREMATORY-NAME tOCAi~Ok Cay Stott
~ , ; ? CREM~i~ON
Q REMOVAI Pinelawa Hemorial Park Milwaukee ~IiscoAain
~ 2ta. 21b 4~c.
€ .',=jBURMI-DATE ~'~'~o*~tA Doy Yeor FU~ERAI MOME-NAME AND ADCRESS S~rett or R.i Q No. Cif~ or Vdloqe Stofe Z~p ~
~ ~.e. Nov. 7 1974 zs~Fred C. Fass ~ Son Co. 3601 N. Oakland Ave. Milwauk+e~e' ~tisc. 53211
NNERAt OiRECTCR- ATURE REG~STRAR--SIG RE ~ ' O~t RE ~o sr a~a~st~cr
~ ~ /~A ~ ~ a~_,~yA~~~ Ga ear
/ ~ ' ~ • ~?1 i
C~t C- fl " ' 260. , .
- ' . '1
This is to certify that this is a trae and co~r+ect Bep~odaction~o~'_~t1a6 rec ~
filed in the Yital Statiatics of ths Hilxau~ee Aealth Degartmeat~:
~ Dated at Milxaukea this 7 ~ d~? of - ~l~L~+ ~ . ~y~ ~ 3~'t4 ; -
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Coasissia~er af Besitb R
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FILED , COUMtY F~A.
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