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HomeMy WebLinkAbout0241 . ~ , j s - 3~Yy. . . ~j`;; ,~;1+;~;- . ~y r~c ; , < 3Q~~~~ i Eu ~ ~tcaRaEO ~~I~RiV t,. ;_;1 S ll•G•c :1JNTYFU. ~R~;~,; r":I~R~S ~ CIf=K ,;:':•1;, "vQURT arrn-~ v~ ~ - ~ W~N/~[l0 ~UMN sTATt O~ TEMN[SS[E - ~o"~•~o+ OEPARTMENT OF PUBI.IC HEALTN ~ 2~.4 PH NASHVII 1 f ~)t~~1~ " 1„p~w~ W/or~M~, M G. M i N Crr+rr _ . ~ - - CERTIFICATE OF DEATH TENNESSEE DEPARTMENT OF PUBIIC HEA~TH FtLt t+0. DIVISION OF VITAL STATISTICS +=S A IEGAI ,:N PRO?ERIY OKFJISED - IiAM~ ..~i~ r~oci~ t~ft OATE OF OEATN ~rO~i~. i+?T. ?4t~ F~~Ee. d~ ~ 2. Jnne 18 1974 ? . ~Y PERMA- R''`CE rNitE. M~Gp. ~Yi~~CAY ~Y~~~M. Stt ' AJE ~ USS ~'F~~ '.\:!f t~~+ CAT~ OF ~IR~M IYOM'M. ~Af, Y(~~2 EK. 1{/KIfTI ~1tlw~a F~~St YG3. D~r1 MJY\f YIM. ' e:~,cx ~NK. 3 W~1Str@ , Female d~ 6. November 28, 1911 COUNTY OF ~fAiH C:n. !O~/N. O! iOiAT~Ot1 OF OiAiH ~+f:ot c~T. a~~~+s HQSPI~AI OR OTH~R ~!~S~~7UT10>I - NA.u; ~S~FC~f~ .Ei C~ MO~ ~1~ tiG1 ~M [+f.r'i, ::~:E 1'~!!t ~wp w'lr~'~~ t. ~v- Washi n ~b. yes ~e. Nemorial Hos ital ~ii; S!A'£ CF ~[i*N ns y0• e i.~.. ~''~ZEN OF WMA! COUNiRY ~~V:,J bi. ni zt:F9. S:;ir~~~h6 SWUSE us ruE. GnE r~~Ot~ Mwrb - .s;a~ ~Ef~DfMCk w~rE CGG~•~n wiLJ'xfD. D'YOiCE~ iHE~:i.. ~:,e~t D1ce.seD 4{ vu~{ : il. @n i~r ~r CfwIN ~t~-f ~-':ttk0 SalAl SECUl/~Y KUM{ft SEIVKE a~~li ~OKIi LiUAI ~?C:U~rT.:!'! ~G~~! uwD Dt ~•J~t O•ihE OV~~YG K~eiD Oi WLNESS OR IHO'JSTIY , R~f~ON. Gn! 'SHC4~ rw~ C~ 0~'ti O~ tE~~+tl~ rOft W~p~nnC u~F. Frtw q~~aEJ~ ; :~s•~.~ct uwat 12b. RO ~130. gOjII 13b. 'r = u'. 3 S' ~ RESI~ENCE - STA~E ltUriT' C1TY. T6WN OR iOC~TiON ~MyioE t~i•' ur~tf SltfEi AH6 NUWEt ~-~~1 ,,..t~• ~i?ers. +cs o~ rw Tennesaee 14b. ~~si11 n ~k_ Johnso ~~+a fATHEI - NAME MOTHfR - MAIDfN NAMt iNFORM/~Nt - N~tMf wn~ue~G ~~~tE55 ( G ~s. $ R. IInberger ~c. Ada BaileY 1,~. Fred Lorenzen, Johnson City, Ta. . 1~. ?AtT OE~iM WAS C~USED ~Y: [ENTER ONLY ONE CAUSE PER iINE fOR (oj. !b), ond (c)) lt~.tt~ r r ~ 1YYlOIAif CAyZ( ( ~ i i (a) ~'C.~ ~ti!-MoNr?t ~ C~)r S ~ OYf TO. O~ w! A COwfEpyfMtt Of: CO~~~iioNS. ~c wNr. ~ ~ ~ WNKH GAVE t~SF t0 b1 i ~ j:: ~i t~ ~c~ ty t?t, ?1 ~ lt S 7' t~n r l2i~;n 1" tr~?.~ 5 'E IMYEDUTE CAUSF (o~, ouE ~o. o~ wf w Co~stOU[rc[ Or: StATIN6 TME UNpf~- ~ trUi6 GUSE NS( _ . ~ ~ ~Alt 11. OTHEt S~6NifIfANt CONOIi~ONS: co~o~r~o+s coniuwr~M~ r0 eu~^~u* ~or ~eu~r~o to c~use i~?tr ir 1ARi 1(o) ~ AUt07St 1F ffi ~t+t s~wa~wts to~. J 1~lS O~ NO~ MOi~H ~N G~T!lY11~IM4 CA{I{[ ; ~ W YfAtN ~ ACC1DfNi, SUIC~DE. HOwlCtDE. OATE Of IN1UtY ~rOM*N, Mr, ~tu= HOU! MC1M IN)U~Y OCC{7~RED IfNtf~ AAIy~E Of IIUY~T IM ~Ati ~ O~ IMi 11, II(Y 111 , OR UNDETEtMINEO ~s?K~~n ` C:R MEDIUL 200. 20b. IOc. M. 20d. I• ~=~.l:T ; N~i CER• ~N1UtT AT WJtK ~N~E Of INJQ~T Ai MOYE, (A~Y, ft~[A~ IACiOfI, lOCA71ON ~ iftt!!t q f.iA. NO„ C~R O~ 10r11, fTAiE~ ~ CGM~LETE n?ca~r ris o~ ro~ orr~cc ~uc., trG +vtani ~ ~ ;A~ <_RTIFI- lOf. 2py. ~ ~ ~ : ~t HOURS. ~ ~MYSK~AN - CHi~flU•iON SrGNATURE e[e~tt OAfE S~6NE~ ~roer~, awr, rUu t, ,7RE UN• ~ Aii(MOI~ iME OKlAlfO AMf OUfN Q(Cl'[~E~ ,7 ; A~ 1Ml KKl. OM iM( ~A1{. AM~. lO iNE ~kSt Di ~y, J ~ / i,'/ ~ ~ Y• trO+rllOGt. W! TO iM[ (µlttlf/ ttAffl. ~ C s 2to. - l.l.f~ir : ! ~ . . ~z~____ l~~l Itb. L ~7(f Y ~ ~ ~ 3 YEDiGI fXM~INER - CEtT~iiG~tON *~nf OA1E St6YE0 ~rortw, o~~, ruu~ ~ %.";;';~ED ~Y , ow r•: rt;s o: ~r: ic~r~v..t~o.e o• saa ~7~~ ~rJ o~ r~t 1M~lLTI(/~flpll, 1¦ rr o~u~oM, eewni x- ~ ~•~~'NORIZED ~y~~f0 OM iM! OA~! At~ WE ~Q T!Yf CAYSi~S~ R~1~E9. r 9~: u~ R E 120. # p?fOZ jQ CERi~iIER - NAMf ~n.e oe .a„~~ Mwiu?~ ~DOtESS ST~lIT O~ lJA. MO. C~Tf Ol fOMM sr.T[ z~~ ' l =..'i C.F 60DY ~ .-~~~i~ _tt +7 i1r~~ ~:i 21b. I? /i`,"."i:l"?Y ~ _ t~..:~~71 rw• y7~:•/ ~ ;,~RRt=R OR j-~TE Wt1AL. CtEMAT;ON. REAlOYA[ OA~E ~rOrrN, Ow~, ~Ewn CFMETERY OR CREMATpRY-NAM~ ~C,~{(~:-{~~•~ ~!":~~yy p~ f7Ary Y nttcn~~ 'v,!" ~ ''i Y ~+4:'t ' { xo. Bwrial 6 20 t~ Ik. C~.k Hill •$nneeeee , ~ WNERfiI H ME - NAM Ah f'.S ~i:ttlt 6~ ~.rA. MO.. C~~t O~ :W'M. f1~TL 2~p iYv1~j ~,~t N f ~-r 1~: ~,r; ~tu~r[s ~r ioc~~ a ~ .}~+.~;j w ~ r~:~st~~i ~ . = 25. lij.= ; ~ . - #';'~i''~ ~ :i l/ 16b. ~ ~ - _ , . .14-~r:r.. :.~,F . . • . ~ -~-.~i t ' ;,J ~ ~ ~ ~ ~ _i~'~.:. - ~ i ~ I here~y certify the ai:av~ to he a true 3nd correct c~py.x:~~~~~;. ~iiigi$!A ~~t#r~, on fil^ ir. § . 4•,r.~._ this Departm.ent, Valid O~ly ~vhen em~vsseci se~l of ti~~,a~s~~ ~,.t~'ttrr2en*. ~~f Puh: ~ , , ~ r• , Y' • Health ~3r.d multi-color seal of StaL~.Reqistr.a~ affixett;i~ _ ~ . ~EU::.,__~ , Lti~.. , _ . • ~ , : _L'. ~ 10 r . . ~ . . . , v t 1. • _ r~ ' • ~•'+~f S~ ~ ' _'~.~C1A • ~ ~ • ~ / y _ • r~ s• lf:l~ ~ _ ~)OOK~~9 ~ Ct~mmissioner , ~~~E 240 ~ = ~ - _ ,k - ~ Y _ _ _ ~ ~ . ra