Loading...
HomeMy WebLinkAbout0364 - I~w~N~r~~• . Df'~/tS10 ISTICAL RESEARCH AND RECORDt. ~01 W. ~R[STOM fTREET. OALTIMORE 1. MARY~AND ! ~ ~ GERTIFICAT/ OI~ DEATH ~ _ < - - - - - - _ _ _ - - - - _ - ± LA~C E ~0~ D - - - - - - - ~ - - ~ 2. VfU7LL xLiiDtNCi IMI?M~ d~cN?~A I~ved. Y ~eud~r ~w~ R wu ?dx~ ~d~+nuo~) ~.n .s • ` s stwr[ w cou~ir~ a~~ C7 ~ ~ xwaYi.wr~o • ~ n Ui? O~ TOMN (~l cw o w~ ~I.r4. s, t I N G O i S i A Y I N I b i~ --l~ p . t ~w~ wre ~o.. ) ,i a C I T Y O t T O W N (G or~ud~ ~aoo n~ A~ai, ~ d~ RUtAI ~~d f~ve ww~0 Mr~) C~ ~ r~Ti ~ _ - --1--- ~_~,~s __`?x Q-~t- ~~e_--~ ~ ~ e. N~~•.E Of 1 L pt {ftfllTUi (d w~e ~w M~pyl, fy r.e.t add~~u; 1 d. S1R!ET A.^D~[SS - ~ K tEStpE:~CE , Q C ry," ~D ON A fAlM? 'r - ~ "'i' ~ , ~ /J ~ YES NO I flAP:E OF ~ V~ ' - , ~ . . . . _ - ~ ~ .G . tw1 !~ld:.~~ 4~~ DATE Da T~r~ DECCAS~D ~ ~t ~ 1 Or ~,li^~ cr c~~n~~ . l g c ~ ! ! , I I ~ ----h--Q-(!_I _V . 1 ~ ~ t uswsa- - 19 m S~ COtOR Oi Ct' 7. MtAtLtp I! MAILED OAiE Of EI:~ M ' 9. AGE Ilw yNn ~ li UNDF! 1 AR' 11 IA~Et Zt MtS. ~ ~ ? ~----I ~ , f r~ ~M~. a~s w~ ~ ~ ~ ~ MfWOWED MYOtCEO r A ~ 1~~ _ f> 0~ Q t~-_i Y~ r i t Rt QCCL7Ai~CN (~'+.t~ O+ Mpt ~ lOS. KiNp 01 !U`_~l1ISS OR IN9USiRY li. t:CIHiiA:f !Ce.nt~ 6 SWe. a a__~uw.rr~ t12. t1112 N O! W COW. 1111 A ~'J ~:~cv~~~ stp/( ~6M.~n~dnW~l~ ~ . 1 -VI- Z ~1r~ _ '_._..-__..~.A*.~ . _ , J~. i:~ ~t ~ t.Z ~ • . _ i+ FA1N(R"S i~~ - It. MOiHE~'S AAAIDW NAME - - - - - ~ - ' ~ r u:l'I^_r:'t ~ i~a:'~ ~'.i'~~t. il'i:..C~1•] ~ r+ NAS DiCEASEO EVtt W U3. ARMED FORCES?' l~ SOCIAI SFCUUTf NO. 17. INFOtM1lIiZ ----Adlnr ('A r.,,.~ 'ea. ^ . cr Va~OMOI ~~YYM~iv~WIWSiL{~IMfrK1)~ . ~ - ~ j ~ i ' t } ~ Z. • ' ~ r .of .i a.~.l~.~, .....-n:1~. .__i:v~ ..~:'~_i:a•i r - •m ~a` cnuac or as~~ra ~f~~ o.~r o~: ' ~w,. r~~'~. te~r-:s,a ~~1:1 ~ - - ~ : . -~"vj - rvicEv~i utweui ~ ~ ~ PAtT 1. pEAtN W/15 CAUSED ~Y~ . T TH ~ , w~o~.,TE~~~ua~----n'--~-! l~ S _ _i !G-~~57~/~5~s_ ?o ~ ~ ' ~ i~J~~ DUE i0 ~ Q V~ ~1 Cond~~~ons, i •(y, ~lit 0 ~i v ~ lbl------- ?r t~v~ riN b i~k ciuM } ~ ~ ~ x sn!~no t?~ wdedyiw~ DUE TO • r.. ~~~+s ~e~,. <<~ D ~ a ?Atet R. OT11tt S~GNtilCANT COND1110N5 COMRlWTING TO OfATN'lilT NOT RttAiED i01HE 1FRMtNA! DISEASE CONDiTION WVEN W~AlT'i{ej~ H. ~O E~y : m~ • Z~ _ t • • Yrs []'x~ : . ' Q n :Cv. ACCIDEM WAS UlOE[IrING 20b. DESCptE HOW tN111lY QCCUlED. {EwNr wwr~ d~~iury i~ ~an t e~ Fan 11 ef i+~s la.) C:. CGNiRfeUTMIG Q CA(JSE Of OEATH ~f ~;j~ ,f EIiMER. NOTlFY MFDICAL EXAMWEIj % : •~-~G r~t `St I ~ C ~ : „'3 ~ 2t~c. itME Of W1URY Wd~. WY. Yw 20d. lNiUi~ OCCIlkRLD ' YC~. ?LACE Of MIJURY t:b~r. fua. 701. {G.y a tovr~) (Cei,at~r{-r ~ > r+o,~ ~ ww. r+a w?r. ! e.~+on..~,.«. e:e~., e~.~ ! ~ -,f -j. :t y y ~ . o.e.. t9 ,N.,at ? ? I ~ „ : . • 3~• ~ ~ ~ ~ ~ ~ _ _ 7d ?a-I ~ E cQrtify that (I) i o~~1al) at ended the eassd (rom.... 1 . to..... , . "(f~'(we) Csst Y ~ . . = - ` a w t h a decea n... .._...1~~', and tha ealh occvr~d st. 6om Ihe ca ses aod on ` b,/....".. • - , ltt0. d~tt"st~1d abcv~- • ~ 2:eJ5!GNATURE J----~ ' _ ~ d r • ~ -rr ~ ; AITFNDiNG 0. STAFF . 'Z • ~ ' y ` ~ ~ • ~„~a iHYS. OIaECTO! ?H71. ~ i.'I. = =~3: "tx ~ ~ ~ ~ ~ - ~s-------------I 2c. +NrSCtI 'S }~2e. ADDRES . - c ~ •+.7r ~ ~ - f ~ ~ NA~.E M~ / . ~~W ~_4- ` ~ . . ~ - - - - _ _ ' --~r!~-- = - - - a. E:i0.1a1, Ct 236. DATE iHEtfOF 23c_ NAME Of CEMfiERr Oi C~EIMAiOR1 23d. IOCATION~~h, ~o.r~ u ceW7i - _ . G.t1dOVA! , . , ~ , - O ~ ~ I ~C.~'11J~ L?~~' i ~E~--V.~:~ I ?:.~4 ! ~ ....r?~~ ..i~ . ~•.t-a4ti.i~t~.- -Q ~j~ NNEfUI DIRECTOR'S SlGNAi1JtE ADDtESS 25a. [EC'O ~T REGIS(tAt 23?. R[GISTRAR'S :If,NAiURE ~ t ~ - 'iE1 _i ~7:i.$ ~ lYl~% ~ u~ ~y....1 ~ __I• ~GAIE ~ 1 4 ~f'~ ~ - D .s{~ . _ . - „ . . / :aiA~ = ji, .Y~ • F1~tg - . s~-~~1~~:. :s~1~Ty fi~ C~r.-;"' '''f-i.: ~ =-r:` -liI (ttlRl • Fr ~ r • ~ Z~ L 26 'T~ ~s~sss ~ ~ ; , ~ , ~ _ BOOic pA6f ~ ~ - _ _ - - - - _ . ~