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HomeMy WebLinkAbout0808 ~n~344 `,''y ~ - lhis certifies that this is s true copy of a a _ ~ rFCOrd in ihe files ot ihe Mansfield Richland ~~l ~ . Courty Heafth Department - ~ -'4 ~c2~ . Registrar ~ . . . - - - ~ i~. . . ; ~:r. l;~a~;s~ield, Ohio ~ , :4. `.7:-~ij;~?,;~''-~ Y ~ . - . ,~'sy.gy . . . ~ OH10 DEPARTMENT OF HEALTH Dr. Adair RcR~ D,H. No. ~nD DIVISION OF VITAL STATISTIGS NO Pnmary RcR. Diu. No. CERTIFICATE OF DEATH ReR~ur~t's ~o DECEASED-NAME l.n~ .Millfe l.ur SEX DATE OF DEATH r.No~+b, D~~, Yta1 Robert A. KINSELL male June 1 4 RACE p'b.~r, ¦~~.o, ..r.ic+. AGE- t.,r UrIDE! 1 rE~! UNOEt 1 OAY DATf Of sierN r~IoMr4. D+~. COUNTY OF DEATH ~wb+~. r«. ~SlrtiJ ~..~bd~ reil .Mei. D+~s H~rn .Mi~. Yml . K~'iite ~ b~ se. s~. s A r.8 1 1 Aichland CI7V, YILUGE, OR ICCATION OF DEATM INSIDE C1T~ UMIiS NOS~IfA~ O! 01ME! INST~TUJION-NAMf ~/1~~1~rWbrr, jutiht~f.ullrrl~jtt) Mansfield ~s0"`~"~es~' ~a. Mansfield General Hoe ital STATE Of ~ItiM ~l/ +eof i/ US.A., erat C~TItEH Oi WNAT COUNit? MAflIEO. HEVER MARl~EO. SUlYIVING S/pUSE rl/ e~lt. ~~~t r+~Jtr M.111/f/ ~or~tr~/ WIOOwE~. ~IVORGE f5 ttil)I Ohio USA ~o. marr~ec~ Lucille Matthes i SOC~AL SECUf~TT NU?t~ER Ww5 OECEASED EVEt iN U. S. AUrEO fOtCES? ~ ~ 6 0 121~ ~l n• ro, er rrl~o~~l ~t /Jf ret, ~k detes n/ strxi+r? ~ ~ ?o. ~ ?b. I`~ ~ i USWI OCGUMT~ON /Gitt 4i~! s/ r or4 dOSt drriwj sail ~f KIND OF WS~wESS OR INOUSitr E Y!/tl~j Iljf. ttt~ i( rttirdl , ; oWner and o rator ~~s ` tES~DEtiCE-SiA1f COIlHiT C1T~, YIItAGE O! IOCATIp?~ iNS~DE C1fr UMItS STlEET AHO NU~t~ER i ISOtt:lf 7u er Nl ; Ohio ~.,.8lchland ,.a'ro Tp ~.a. no 8T~ 6 m Rd 3 iATMfR-NAME I~irt! .Mi/d/t IJ11 MO~MEt-MIIOfN NAMf I in! ~ ~Lddlt Lnf € ~s. Victor Kinsell ~e. ~ INFORMANT-NAME MAIUNG ADDRESS ~Sn~rr R.f .U. wo.. .~i~ ..iL~r, u..rr, :ipl 8 ~ »e. Lu i e n e ~~e. ?ner i. DEATH WAS CAUSED dYi :EN~Et ONL• ONf C pet, nD rc~t F WEEN~1 N~~! AHElVAA1M ` ie. ` ST.lUC1E COUN - IMMEp1ATE CAUSE t°~ ~se (.ev~.e...~..??a RO~E~ %~?TRAS ~ f 2 ; ~ OUE TO. O~ AS A SEQUENCE Oi~ ' G.s;tio,,. ;l ••1. Pf.rCp., ;•E,~;:~F~•~--- ~~:~a s... riit re , Ibl i~~~di~rt rtaut /s1. DYE t0, Ot AS A COwSEQUEHCE Of: .,,,;.s rti. ~,...-1 M~t ~2 I 4~ PN'75 ~ ~ l~~rs r~rir !ur ~ tART tl. OTNE! SIGNIf1UNt CON~~TIONS (~~Iilio~~ to~l~i~r~i~~ to dt~tb ir! ~e! rd~~tJ fe c+rit sntw i~ Iar! 1!~/ AUiO?ST If YES ~ t~~ 1+~W~y{+ ~o~i~Jr~rJ . ~ ~\~ti or wo ~M Jrrnir~s~ns a.+ru o~ Jr~lb ~ IVe 19E ~ ACC~DENT, SUtCiCE, MOMICIDE, DATE OF IHRIl~ NOUt NOW ~NJURr OCCUR~ED (twla +~ron o/ ~w/rry ~+O.r.t 1 or O~.f 11, i~~~e JM/ - OR uNDEiERM~nED /SDeril)I I.Mo~~b, Dr~, Y"tn1 ?OO. ~Q . 700. ~NJURT AT WORI( •IACE O~ INIURf Af ~o~rt, I+~~. J+~rorr, tOUi~ON tSnr~r o? K.l.ll. ~o., nr~ o. uR..j~. sr~~r, irp! fS?~ril~ ~n o. +~01 o/~rr Nd~., ~ta IS~eti/)I a. aw. CEtTIftUTiOH- .Mo~tb Dw~ F~w .Mo+~rb D~~ l~t.n A?rD IAST S~W M~rt/MEf 1 DIC/DIO t+0i OEAiM OCCUtIEO .tr 7br 0l~rt. o¦ ?MYS~CIAN~ A~IYE ON v~Ew TME ~ODY ~HOU~} +tit J+~t, r~d, (o - t AtiENDED iME TO .Nestb D~~ 1'r~r wifER OEwTM rh~ b~~+ ol ~ 1 4 73 ~~e. 6 5 74 6 5 74 - z~did not z~. `ti~."~~°~ ~?°<i:~ 71a. DECEASED flOM CEtTIf1:J1TIOH-CORONER~ O~ !b~ Iwii~ o( 76t/ir~wiw~tio~ Horr n/ d~~rb Thr /rr~Ji~~ p.oAUrwirJ Jr~J • _ ol ibr ~ol~ awd: or tbt i~rnti{+~iow, iw w~ ~?~~~o+. Qtet6 .No~~b D~~ 1~~r florr - v~irn~d os tbs drh rw1 L~s to tbt r+ru(~1 i~r1tJ. ~ 1]~. N 114. - M. CEttINER-NAME /T~Dt or Pr~~1/ S~GNATU „ I)iprr v. /~/!t DAiE S~GMED ' D. N. Beddard, M.D. ~~b ~~i~i.-<s' ~~6~>~/ Y°# ~ i+tA~U?+G ADOtESS-CEIt1~i~ER SiREET OR R.f.O. NO Utr OR v~~~wGE St~IE Iv ; 480 Glessner Ave. Mansfield Ohio 44903 WR~AI. ClE~tAT10N OAIE N~f Of CEI~EiE~Y OR CREMAiORt IOCAi~Ow r( ~r~. u!l.rsr, u. .~rMry ~ ~Nrn1 ~~0 +l)1 ~b~uria ~.y6 8 1 4~•~ ~~a Eichland Ohio ~ NAME O~ EM~AIMER (UG. NO I iuNE~~I OitECTO~ S StG?+~~uRE (UC NO i •t; . ~ ~ 73 rl e 76. ~ ~ _ NnERAt F~RM ANO AOOtESS ISttEET n01 (Uit~ ISi~iE1 ~1~~~ ~ - z~. Ch D~1E ~ECD {t REG~ST t S S~GNA~URE O~TE ?E~~+~T iSSUED S~GN~tUtE~~~E~~NG tERM~ DISi. NO. ~ ~o~r ~ ; ~ , ~ ~o „ soac ~as~ ~ ~ _ _ = ` . ~ . , _ _ _ ~ _ . . _ w _ r,,-~:,.-_