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HomeMy WebLinkAbout1128 . _ . - - - - OH10 ~EPARTMENT OF HEALTH a~O~~ NeR. U:u. \o. r.7• S~ 5ua File No. DIVISION OF VITAL STATISTICS ~ . N`~~'„`, K`R. p~u. ro. ~5C! - CERTIFICATE OF DEATH RcRiuur's IVo_ ~1- OECE D-N ME .N~dJ/e fr SEX DATE OF DEATH f.No,.~b, U.,r, ]'r~?1 / t. ~/7 ( C ' Q 2. ~ ~ f,~ RACE u'bir•, ws6.o, arroiww AGE UNDER 1 YEAR UNOER i DAY DAiE OF 61tTM I.~I.~tG. Da?, COU Y OF DE~AT • ' r.rJuu. eli. S af j bi~r Y yI~rJa1 .11ui. 1).+rt llorn Jlir. v / ~ • • 1. ~r~i So. / sb. sc. e - - 70~ fIT , v I~AGE, Ot IOCATION EA7H INSIDE CITY UMIiS MO R MER STIT ION ?Mf r1/ Mof iw ~itbe~, ay' t~h~ rMd rwwbt?I ' ! fSD ri .~et or wo1 ~ J 7 ~ n Ci ~ 7c~- ~ i.~ 7d. / ~ S1AIE OF E~tfH, IlJ Ma1 ~ L`.S.A., r..wt CITIZEN OF al(I AT COUNTRY MAR O, EvcQ /MnRKtFU~. SU~~. vING rOUSE _71~~e, ~Tre s~ tx euwt) .•.rrn~1 ' ? WI E IVORGED IS t~ilY? l j 8. ~ O. 10_ % il_ ~ ~G / t SOCUt SECURITY KUMaEi W~S DECEw5E0 EVER ~N U. S. A~tw~ED FORCES? ~)"e~. ~rn, or fI~N~JY NI f IJ ~rt. 6iiv u.rs or d+r s o~ ~trrire) ~ °'CENCF 120~ ~ ~ t tJb. C _ L"" ~ 7 4 ~ ~ ~ : ~EASED USWI OCCUPAiI ' Ea TH j fC;ire tird oJ u or dore Jwri u o/ K~ QF 6USINESS OR INOUSTRT - ~rl u ~litra~iJe. tu i retirrdJ G~VE 1~- 2 i ~b. '.v / i gEFORE RESID€NCE' iAiE COU Y C~TY, YILUG R FOCAiION ' INStDE CITT llMliS SiREEi AND NUM6E ? / _ / ISOui/7 r or w/il i / y``' L' ~ ~ , L~~ ,.eL . . ~ f fAiNER-NA E~. FinJ :1Gd [ ' . L.ttt MOTH -AIAID ~ lL- / _.Gj , tl , / . ~ s s. ~ . / 16. ~ ' / ~ ~ / ~ . ~ /C/ ~ MANT~ -NAM ` _ti~ ~ MwR~NGAqD t 5 SJ.ttly~ • .D. so.. 'rJ ti!(~a~. IJ . / i ~y_ ~ ~ 17 ~ ~ 17D. /G ~ -ii~k'-> ~ ~~-~-C~ ~ ?A4T i. DEA7H W~ USEO BY: ffHIER ONIY ONE CAUSE /f i1NF fOR (o/, lbl, AND /c)) A?PROXIMAIE ~r:SEkV:.i A lETWEEN N ET AND DEAiH 18. ~ L IIYIME~IATE CAUSE (o) ~.11~ ' ~ ~~1 _ ~ ~.o'~~~~o~~, ff ~w~ OUE TO, OR AS A CONSEQ NCE OF: ubicb 6rrt ~ur ro ~ Ibl UR~t6IIJl! fJL{[ 1u1, ~ DUE TO, OR AS A CONSEOUfNCE OF: - ~ !lJ!l~JR /Il~ YN~It/- ~)IIf6 [JYt( ~Jll {C, ~ ~ ?AtT Il. ~Oil1ER S~GNIFIUNT CONDITIONS ~ GB,IlI/IMI f0117/ISNflMB /O ,I[JI~J GM~ A017[I4If1II0 IJLf( jIP(1/ f1 DBII I/QI AUTOPST IF fE5 ~rtit ~+ulrwar [oH~iJrrtJ : - ~1"tryr wo ~w drnru~isiwa t+rir o/ dn.rh ` ~ ~ ~Y1 19 . ~ 1Vb. ~ ~ ~ ACC]DENT, Ut ~DE, MOM~CIDE, DA1 Ob~IN1UlY HOUR MOW W1UR~ OCNRRED /F+rrr o~ture of ufrry is p.+rt ? o? pmf 1/. ilts Jt+/ ~ ~ 66 UNDETEQMMED (Spacil~l l.11~Mt8, D~r, 1"a~ . ' ~ ha. ?0~. . J_ 7 Z' ZOc. lOd.. /f _ I. ' I _ i _t ~ ! IN1UiY A~ WORK ?IACE Of INIURY'~f b~i~wt, J~rm, ~hrtl, f~[Inr), IOCAiION IShttl or X.F.D. [il~ o? rill~6t. ~ldlp, ii~) ~ ~Iprri~;~ri o. wo% orj.ie btJF.. t~r. (S/:r.il)I ~ 20~. ~ 70f_ 70q. CEi.TIFICA710N- .11owtl~ ll~i l~r~r .~I~..rtb 1).+~ l~t.rr AND IAST SAW N~l~t/MER 1 DIDJDID NOT DEA1N OCCURRED Af fbt je/.ttt, o¦ PMr51C1AN: AUVE ON vlEw iME 60D1f (HOUR) tbs dalt, r~d, to ~ ~ 1 ATTENDED THE TO ~1lontb DrJ )~~ai AFTER DEATM. Ibe btit of ~w~ ' twoaled;t, dat to i Zlo. DECEASED ftOM 116: 11c. 21d. 2ie. M. lbttrrt~ltl fJ.utd. CERitfIUTtON-CORONER: On fl~t b~sit o/ fht txds:ih~linR Hoer o~ Jrrtb 7~br Jrr~J~rrr u+r prono~ntrJ de..J ~ ! rbe bodr r.~J ~r tbr ixrsrtia..tion. iM mr opieios. Jmtb .?low/h U.+~ Yu? Ho~n ~ pICYrIf~I OR Jbt (Il~[ Jqfl ,IMI ID fBl L./4f[/JI i1..led. 7Z0. • ~~b. M. ; ~ CERTtHER-NAMf !l~pe or p.iefl SIGW TU ' ~~r Ded.r~ or ~it/r DATE SIGNED _ ~ 230 ~13b. ~ L L ^~n~ ~ 1~c. ~ ~tuNG AODRESS-CE'f~fjER _ SiREET OS'A-?-~• U?Y R VlllwGE Si E, ZII ' /l.l % . . ~ w i. ~ ~ _ ~ ~_~.L.____--r_ lUt~ CREMATION ATE NAME OF CEMETERI' OR EMAiORY IOUTtON it~, ti!l~6t, o? toretr f~r , ~ r1 1 . ~ 2 71c. A 21d. P ~ •AAS+E F Ew6AlMER ~ ILIC. NO.) fU ~IlEQOR'S SIGNATURE ~UC. N.) f 5. ~~Y ~ 7 26~ ~ ~ / z fIRM AND AOOtE55 ~ ISiREET ?~O.) (Ct " , ($il~I ` 'L~ " ~7 j ~ ~ ~4, / ~ ' ~ REC'D ~7 REG SiGtr URf OATE /ERM~T ~SSUED StGNATUtE OF tERSON (~SBt ~~i,Mjl~•~: ' 5T.:1i0. ~ l REG. ~ : =~~:~j'~ ~ ! ` j ' ~ 1~' t'~_ ~ ~ 3 ~ 30_ )1 1 ~ ~ ~ ~ / / . 1 LO ~ . . _ I y'~- ~ - _s~.:r.~irs--..-.. ' - - - - '.1,. . r.' .:._'`d. - ~ . - ~ ~ Fi~EO P~co~oEO s.., - f -i: : ~ ~ ST. ~uc~' ;.~uNtr F~~. THIS IS A COPY OF THE OFFICIAL CERTIFICi~T~"• A ; ~ R~~_. ~i~RAS - ~ : .~y~ ~ . ; r . t C4c5[ ,-.;~,:I CO~JRT , ~ , f S.: . ~ , ~~~~r, Y`.~~''~----'--THE COLUMBU5 DEPARTMENT OF HEALTH 1VC~ 4~ ~ _ • ~ d„ . ~-~r^.:'. r FE8 13 ~a 38 ~~'75 . • • ^ . ~ U R ~ ~ ~ ~ 3412'~''~' ~ ~ aooK~ _ ~ RFGISTRAR DISTRICT #25 ~ ' ~ . _ _ . _ ~ ~ _ _ _ . . _ _ : ~