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:i Gcor~ia Dcpartmcnt of Human Resourccs
Vital Rccords Unit
CERTIFICATE OF DEATH Stab F'i1~ Na
t rJ
sr11TH tt0. 1~t'iG1{n Dta. N~. ' Custedian'~ Na
!.-DEla~tD l ( ) . ~ ~~r)
1 (T o~ hiul) D~/V W DfATN ~ I/
D / 1) ~ w~ d~c ieaA oa: ts~id~~c~ c~ ~der'
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aaa ~ie+A ~r ~t~t~ ' STAY ~s aed Nw
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s. sac s. ct su i.n s~.~. « • r t~~'1 ?n~ Peiel~L
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ya ceua COOItiltYt
I ~ ~EW ~OR,~ I Yw p tte Q I ~t7~loWIL ~
~ A CIlFi~1ATI011 p 7~17~77
DATt AG Is UlIDER 1 Q ONDE~ !A liAS. C 11 II ( er ewa) )(alat~
lad DiNdaf Me~1b D~r Hean Ifiu.
3-!O -O 70 I I - I Cremator Fort P~erce-St.Lucie~la.
10. MARI~IED E~ l1AAAIED Q U ~d ~ Widew i~ aah e! w~~ 7. G Cf~tSy
W1D0 SEP !ED
~ ED O I @~
*hsrine p~o
i~. usu C11PAfibl~i (Giri
bod oTrreek ~~a t~a os i K ~ .
do~~ do?ip aest el wer IJ~. ft r~tind DY8I1T
Administ~t~ve Asst. ~ept. of Correcti H. N._ Aa~tters~n &-Son, Spring ill
12. WAS DECEIISED EVE1 IN . AC 08 IAti' D
(X~~. ee. e* uaksews (1! !H• yi?~ w~t w dabs e/ wr~~)
No ~ ~ --'/(0 1020 S rin Street N.W., Atlanta, Ga.
13. FA •s - ,.e~
~t'p ' Mrs. John Edaard Adams - Wife
Mo •s iwc . a~- nna
LL 101 rial Wa Fort Pi.erce, Florida
22. CAUSE OF FJ1lH [E++1~r enlt ea~ c~uw p~t Gn~ let I,a). (e). aad (c).~ PLEASE PAlti! ONSET /?}~ID DFJITH W~
PAE? DEATH WAS CAUSED DY: - - ~ - I
II~WEDpITE CAUSE (a) ~ i•.•: i : ' % :
~ <<' : .i T~l~ /_~f-~% `~L -
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x Conditiow N as~. DUE TO (1)
O w~Lic` Q~~~ ~iN N~
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t ~!iheQ U?~ uad~t-
V lyiap ~taN ~~N. D~ ~ (C~
PM2 !1. OW~r dQai5c+a1 cosditioa~ cwtr:butiaa to d~~W but nW r~lat 1e tL~ I~rmiaal diwas~ coadibo~ pi~~a ut I(~) I 2!. AUIOPSYt
~ : i~i~ ~ ~ ~3 Y~sQ Ns
I 2/. ACCIDENi PLACE OF IIJJUHY (wq.. is or m u+~vaY occus~n
~ SUICIDE Oibea~.l~rs.lacleh. ~tr~~~ Whil~ at Werk Q ?S. I D~f~ilj pt1~ I i11~1~d /M ~K~iNa ~+~d `~L: 1..
r HOl41C1DE Qlo~e~ Dldq.. Na1 Not Whib af Work 1! 7 E , N l•~ ( f - 1! ILaI I Lat uw tb d~e~as~
~ ~ (C[TY Ow IOWN) (~7ATE1 I ~ ~ (MosW) (~~7) w) ( ood ~N ~ .l
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~ HOW DiD INIUIIY OCCURt ~IU~T d~~~ T' tros 16~ e~usu ~ad e~ fb~ datD.bt~d abe~.
q~~~ K T
~ ( (
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~ 2~. DATE AE ' b ODD _ / DA Gt~(ED ~
REG - -
~ ~ ~ ~ ~L~ = r.~•//.•. - ~<i << ~ ~ ~~1: i
~ oA515)-3 • • ;
~ l t 2 56) _ ~ _ . ' :i
~ Decatur, DeKalb, Georgia
~ This is to cert~€ ~r;~at the above is a true and correct copy of the certificate
~ that is on,- lE~;~~$ Records Unit, DeKa1b County, Decatur, Georgia.
~ ~Z:;:::~ +
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~ Directb~.'d 1b ` ealth Department Local Custodian, Vital Records thtit'
' Local !.~eg~ ~~e 'Cot~nty, Georgfa DeKalb County, Georgia
~ '^si~~-'~=:. !r~~i ~ - ' ~ .
~ • ~ • ~ .
~ ~ ~y R:T1-~-~~ . ~
~ ~ ; . z. . 1
• N
~ ~9 18 1975
~ `~~Cj Date issued
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~ o ~t r A~.~158
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