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HomeMy WebLinkAbout0184 ~ 'REG~STRA710N , iTATE Or II.lINO1S 3-. ?.~r`u~ : ~ ~ ~ 6'7330 ~ ,J~STAICT NO. ~~~C ~-y ~ , - ~~~M ERf~ ~L•'~~ 3~~"'~L CERTIFICATE OF DEATt-R ~ ` DECEASE~--NAMF ~uii* - M~oat. ~N* SfX DA7E OF OE/?TH ~r, rtw~~ f ~ ~ i ' i~ - ~ 3/~'~.9/~~ /9 7a .X. ' ~ RACE wN~~[. w f/t0, wrtRKwp u.W~w, vE-twsr . NDER 1 Y~(AR • UNpfR 1 D ATE BIRTH ww~iK a~. ruu~ PIACE OF OEA7H t ` ciC. lio[Girl ~t~i~~Wnlrtil~ MOS • M~S ; ~iOl• ~S . - i ^ ' ~ So. . Sb. ' . Sc. ' 6~~ • ~ 70. c~Tr, ~Own. lw?. Ot ~pw0 p11tKi Muri[~t '~NYOF C~i? ; NOY.TwI OR OIWR ~wii~t i~p+-~+u+( Ui NOT Iti GTM[~,WV[ STR T wr+p M~W[~~ . .lvl3/rw~. , ~1 ~ 7D. ' 7C. : 7d. ~ Q SiRTr~PU?CE niwTt w wa[K++ CITI2EN OF WMA7 Y MARRIEO. NEVER MARRIED, N E F SVRVIVING SPOUSE c~~ r+~~~• W~ ~+~w ?+M.[~ - cc+,~.ts. ~ ~ WIDOWEO. DIVORCEQtva~r. ! - 6. 9• 1 U 1 . SvCiwL SEC RI Y NUM ER USUAI OCCUP/1TION . ; K~ND OF BtiS~KESS O~ ~N.7iJ TRY ;U.S. WA ETERAN. W OR OwT OF ERVICE ,~rti~hW ~ ~ J ~ • 13b. O ~ 13c_ ' 13d. ~ - RESIDENCE • sTwft : ou..r. • cnr. iow.~ rw. oa w+o a~r..c~ w ~its~.~~ioir ~ STR[ET AND NV~Mja , : _ ,.~,.Z /~/No /S ,,~U ~ ~~iS~i~ iPna , ~S ~,,la , ,E , i.~.iH~R-Nl.ME ~~~sT - ~?.t~.i awsT MOTHER-MA/DF~l1 NAMf r ~sr w t~sr ~ • ~ 16. ~ .C ~ / ' ` . c ~ R L TION MIP ~ IUNG A ESS /STA[ET . OR ~ i. O_ C~ir T STAT[, ZII ~ iNFOR Sl~il'NTUR ~ ~ ~ ~ ~l,O~~J'i?j'"Y ~~1/'~ V ~ ~ t~~ 0 ~ ' , ~ 1 7r,. ~ ~[TwEEN O~+S[T wN0 M.AiM ?i.RT T WAS C~USED SY: ~E~+TER WA1I OKE CwUSE ~Ell UM( i0t NL pl. /WD iQ) ~~'~T~ ~ f~vw: ' - - - j IMM[OIAS[ CA{ISF . ~ ~ , ~o~ . ~ ~~1;~-~ ~ ~Cc~ ~.I'l ~ iJ l ~ - - - - o„~ To a „s „ ~ ~ CO~`~D~T~pNs. Ii ~ Hv. 1 y ~ ~ i ~t ~ J~'" .5~.(.t i~~s.S _ : w,..i~H C,~vE p~s_ 70 {bi t~ MFD+wTE CwbSF taI STwT~wG T~+f u~OEa• OuE TO OR wS A COnS[pUt~+Ct O~. ~ ~ ;vir~ UuSE twSi. ~ s_~~ ~ ~ ?ART Ii. OTHER SiGNIfICANT CONDITIONS. cwa*~an ca.nNU~~.c *o awT.. wi wor ~uwTto To twust c~aH rw~T ~ w~ AU70PSY • r lr[s. .n.~ ~..o.~c~ co. ; ~ ,C' f k tvulw0: ' ~.aa~o a.~.~.~.rc c.w ; o, p.rw 19a. ? :19b. ~ ~ ~ATE OF OPE~2ATION, IF ANY.MAJOR FINDINGS Of OPERATIO~i ~ - - '20b. ' i i CERTIfY THAT TO THE 8E5T OF MY KNOWLEDGE THIS OEATH OCGURRED AT ~~~Q ~ M., ?vOTE: TM S DEATH. T E COtiO ER MUST i _ ON THE QA7E, A7 TME PIACE AND FROM ?NE UUSE(S) STATED ' BL N0T1FIE0. i~ATTENDEO TME ~~'~TM . WY • rfA~ M~OMiM ~ DAr • Y(AR ~ ANO LAST SAW WM/ MOMTM • DAr . YEAR DiCEASED FROM: ~ TO p , Mu wuvE oe~. : ~ 21 c. ~ f ~ 21 ~ I J : 2, 3 ~ _ SiGNATURE ' 1 _ , DATE SIGfVEO 1+~w+rw. owr, vW1 . ILlIN01S LiCENSE NUMBER - 2:0. ~ ~ i'.L.~ J~ t ~ z~b. z~~ ~v,A1UNG AODRE ~ RTIf1ER ~ STI1 (T AMD tW~tCi O4 ~ f. O. ~C~T1r OR ~OWr1 ~ STwT[ i~ - ~ ~ 3 7 a ~ i~~. -v~ - - a y ouRi~.l, CREMATtON, .CEMETERY OR CREMAT0~2Y-IVAMC , LOCATiON atr at STATf , ~ATE T~. a~~~ ~:4~ aE VA~cvcc~rn ; ' Pock Is?and Illinois 'rar.21,1970 2.;~urial '2aD-.e~:orial Parl: :2.~_• : zse. ~ I FUNERAL F10ME NNNE - sr~ccr ww Kuwu oa R s. o. an oR Taww STwT[ ZV ~ - 6C6 0 Cerm.~k :lineral ?ircctors ~31;1~ ~ToC _ R~, Cicero I11.ir:o~s 5 ss~. - FUtvERAI DIRECTOR'S SIGNA7URE ' r / :rw+[~ ac[cTws ~uw+as ucu~sc ~a+~.sca ~ . -•_=~t~f~/~ : z5~. 5~3~ ~ 25n ~ ~ ~ S A. t~. ~DAT ~ BY LOCAL REG~STMR%~+,. M• ~ ~ ,:.CCAI (tE ` R 4'S SIGNATUR~~ ' ~i~~'n ~ I~~O ~ !~f,~. D LCG>i! ~ ~Q NI1~SD E~ , c~u~ : ey L ! VS 200-(1968) IIUtaWS DE1 MENT Oi Vu6UC MfwlTti -~tMt (MSEO ON 19N V. 1. STw?~O~nO C[RTIfICwTE) ; ClE I~ tiIR W C4URT ~ _ _ RfC030YE~lfiiQ...~....+ - ~ - - - - - - - - ; 2 s9 P~'T5 ~0~~~ - - , ~ STATE OF II,LINOIS ~ SS ~ . ~ CoUNTY OF DuPAGE I, Ray W. MacDonald County Clerk in_and_for the County : ~ and State aforesaid, and keeper of the files and records--o,~',;~he reports of ~ ~irths and Deaths,do hereby certify the above and for_eg~~.~ = 4Lbe a full ; ~ and complete copy of the report as the same appears from~:-~t~i~•~i.~~~ and ~ . ~ n office remaining , ~'~y~'~'~ : ~ ` - . . - records i tqy • :~s' ~ IN WITNESS WHEREOF, I have hereunto set n~r hand and' afPi,~~~3:;t~ie , s eal of n~y ofPice at Wheaton this vj 3z~~ day of .19? ; ~ , ,.,.r •f ~ - f±~4 ~ _ : ' r_;, ; - ~ ~A ' ~ - ~ ~OOK ~:JV PA6E ~~'t , : . ~ ~~~titity C 1 e rk ~ ~ - - - ~ = _v_._, _ . _ _ > _