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HomeMy WebLinkAbout1421 ~ ~ - C£RTIFTCATE OF DEATH se.~. Fai. rro HIATtI NO. N.:G~ia Dis~. No. Cuttodian's Na ~ 1. NAI~IE OF (Fird) l~d~~) IL+M) ( 2. DATE lKoniD) lDa7) (Y~++) DECEASED ? p_.o ( n°~+re a ' 19 1974 ` I2yo~ or Priul) JQI~Q~ IX~-~h ~~q~~' ~ PLA C~ DFJI ( uuatT) 1+SUAL $GS:DENCB lWh~r~ d~c ~as~d 4~~d. p ia~titufi~as r~aid~nc~ D~Isr~ adsi~aio~) r ~,b(~ Stat~ ~i20 g-(.Q Coua~T '10iUC0e ~0?tA~ Is Cit7 Limib LF.NGTt1 Of la Ci~~ L'aib L G O ' C:rf or 2ow~ V~s ~ Ne ? I SiAY ia tSis p~+c~) Cit~ or Y~s ~ No O SlAY lia tbL plae~) ; 1lacon 2~ hn.a. _ :o.~.~ Fon,ac~th ~ Na~ o! Ho~p. os ~o~ LENGTH O StnN Addr~s~ or 14F.D. and soa Ho. : ~teci.i.ca.e Cen.t~c o Ce?cth.ctL Geonq,i.u I 24~~fv~.d . 311 Nonth tncli.an Sp?a,~n~d ~n. ; s. ss~c i. a~?cs i. irn tsw. «~a.w. ~~=~•r~ co r°i s. ~s s~sm- t '°~~ovnc o~ 4/21 /14 ~ f~ I ctJ ( He?Vty co. ,cQ. ~ u~' Y.. ~ Ho ,p _ I ~a~,,,,oY o DATE OF DlSTH 9. AG (Ia TNes~IF t1N~~ 1 IF' ITHDEB 21 HRS. PllWE OF CE1~iED1~- LOCATION (Ci1~ oc Town) (Gast1) (Slat~) i o?uoe ~lemon,ia~ Ganden Foh.ey.th-~lo?vcoe-~'a. Jan.9,1908 I~~ f ~ I ~ io. ~.usn~en ~ rrEVFa t~c~?w~im p u r~.n+.a os vr.ao,..a c~.. N,.. e~ svo,~•• 1~~•s ~cru? uct~ ao. wtnOw~'~i D°a ° ~ Ru6y Nou~i.d 1~.inal~x - r~~ ~..~~c~..,, I 1830 11. USU111 OCCtlPA cc~.. ti,a ~....k D o vsaitss oa ~ oa cur . a°^• ~"'°9 ~''~"a' °~~,~,n~ ~ dneiv A. U.i.Y,Lon ~ Son FunQha.t Kome, Ine. _ ne,Lch.ed~`.~:~,ene'~o~.p. 12. WA9 DECEASED EYEE III U. S. MMED FOS 3. 50 SEC. NO. l9. MOA iJ1t1' ADD cY.u~°"`°'m.••~~~dl'c:1;',T~~`~'~c.~~}~54 P.0.8ox 265 ~o~r~tk, Ga. 31029 1.~FA7!lT~t•s It ~0. IItf~1~ Hdati.aaLly John Cteve,eand ~.ing.C~ ~ 1?Ute . Ru6y Nowr,i,~ fl.inq.C.en cu. dou? ~ 11. MO 8 MAIDFI~ !f 21. i2iFO~MANrS ADDIE~! I~~any Lou Twtn~t.paeed 311 N. Ind.i.an Spn.i.r~qa fln Fona y~h, qA. ~ j CAUSE OF DEAiH (Fibr osy oa~ c~w~ pw tis~ I~r (D). aao ia).] PLFJ14t PRiM OtiSET A.`~ID DE11TH 7. O W91i 1H ~ ~ P.IAT 1. *-~EATH WRS CAITSED EY: ~ b L.j i~/~ ci l ~h •<< l! t r r G .2 or~ 1 ~ ' IMMF~IAT6 CAQSE Z. I 0. (1. CaI-o q~~ y /~ficth o,si. ~i~c !i Ij~ I~[•:, r CondiNo~a, i! ae7. DOE r0 Ib) S. p whitb ya~~ tls~ M ~ sbe~s eaus~ (a). ~ .~~tiay tb~ md~- c~ iTin4 caus~ t~st. _ DQL !O (e) ~ PJ?R! li. GWK p~1 COddibeCl ce~tribYti~9 M d~a1h Shc oW t~1+t~i to ta~ t~rsia~l diwas~ ceaditie~ qisM ia P~r1 I ta) I 23. AUT9FSTr YM Ea o w • J 1.1. AcCIDEKI p PLIICL OF II'tNRY (.,q.. i~ « ab«d II1IlJET ~~r? / 4 ' ~ SUICIDE plho~~, i~r~. factaR• ~t*~t• 1N~'1• at Work Q ZS. 1 i~r~i1 ~M~T tiM I aM~A If~ d~e~wd tros HOMICIDE Q~offiN bld4.. ~ee.) Na Whit• Work O 1!~'~.... M `"n~ ` 1l7~ - thaf I Ias1 uw ths d~ew~~d : } (CIT7 OR TOWN) (CO ) lSlATE) I T~ . ltioatb) (D~1) (Y~ar) (lienr) a- 1!'~ - ~~d ILa1 ~ ~ INNIlY d~a1L eccurr~d a~~~%r!. tre~ ti~ uuati and e~ th~ da~~ sbt~i abew. HOW DID INJ~1iY OCCITIT 2i. SiGNA pr» w T•tl~ Ef~S DATE S[GNED/ 2~. D 'D D . D ,/"•~,G/y~ ~~i ~/°Z • / / ~ ~~A~R30 ~ 4 ~ ~orq~~ epartc~~at o u u •a ~ qDa1 5.3(12-i-56/ ~[U^i M'- ''Et+UM o Vi'al R~cords S~rr.c• ~ ~.Ul,': .;i1;l~~~i R0 ; = F <A5 ~ Pt E :i : ~:I:` 4~URi • ~ ~ ~ - . - ~ " , ~ -s.~.,~,.~,.~ 9 ~ ° p ~ ~tate oP GearDi~ i7 ~9 ~~5 ~ZZ ; . s~ Co'an..y 3iB3 ~ ~ I i~ereb-~ crrtii'y thaL i~nL foregoi..n; i~ a t^ue anc: correct ~bstrtct , ~ ger~.~~nt record of ~e~t~.~ on ' ~ ~ of tih~ ~~~t~ of ::e~L:. a~ sl:o~~~n o ~ Ie ir. ii! ~ _ Of.°~~e:. ~ ' ~ ~ ~i~ne3 ~ , ~ ~ Cus ~.n o£ Vital t stics t~~-c~ s a ~ APR 3 0 1974 t ~ ~ate Issue~ ~ ~:~~L 1 ~ ' ' U~Mi ~5 ~'~bFs~ t.. ~ • ~ - _ _ _ ~ v ,