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HomeMy WebLinkAbout1562 CERTIFICATE OF DEATH • sTwTC o~ cwur+o~N~~-oc~wsrwcNr or Hswt,r~ 900 249 -S1AICTI[T~Uf1A~^-- OFFICE Oi TME $TAT[ REGISTRAR Of VITAL SYATIS~ICf' EG~ TR~f10!1 OiSTR1CT~\D CCqTfF~IC~{~NJ~NF~t t~ kA~IE OF OECEASED-~uKT nawE ~ b M:pp~E MME ~ k. U?ST ~KE K 2~ DATE OF OEATH-rorrr ou. ~tu ~2a ?wull 1~,*anRF:w ; Ar.T~i~hY ;KOISCN KOJ~5 Jui 2 1. ;8:~ A 3 SEX 1 COIOR OR RACE 5. &RTHPUCE ~o;,'~,~°~,',"ON"O" 6. OATE OF B~RTH 7. AGE ~u+~ n u»~t~ ~ n~~ t~ uro~~:~ ww~s ~ ~ h`11.P C;~uca~i ~ 1vc~H• York Jul. 2 1 1.4 61 ,E~,~ :_.:FDENT S NAYE ANO BIRTHPIACE OF FATHER 9. MA70EN NAYE Akp BIRIHPUICE OF MOTHER 318465 ~ ~~;;orva~ DATA nth~n . oiGch - Czech~~l ~vaki, Rn~e L•adic - lew Y~rk W pT12EN OF WNAT CWNTRY It SOCUL SECURlTY NUMBER 12 rucuio ~nrv r~wta ~~ooreo 13 NAME OF SURYIVING SPOUSE nr rue ~rr~~ ~uo[w wi~ea E aro.c[o ~s.cc~n United S ~1±e~ 07-~.0-259~ ~~:arried Dorothy Kellyhouse tt lAST OCCUPATION I5. """0""'"' t6. wueE Oi L~St E~KOrwG CO~tivr Op ?~W KINO OF INWSTRY OR BUSINESS "`~0~~'~~~ ~J4UI~~lORlLlillTf~ Productior. ~ Ford I?'otor Com any Automobile manufactur~ng 1pa PV1CE OF OEATH-NAYE OF NOSMTAL ON OTMEN W-PATIEPIT FJIC0.ITT ~lda STREET ADpRE55-~sncEt wo wru~ w ac~nos~ ~t&. ~¦sro~ cm coaroutt uwn = L acE , ~~snu...a o, wo, cF ~ 3829 Brian ~~14~ ; ves ~.CaTH 1t~0 CITY OA TOWN ~18[ COUNTY ~le?. u~srw~surncou~~~pa~n ~18C, ur.uav~~+~t~rwu~ So~~th T.ak~ T?hne ; El Pcirldo i?. davs rtArtt ~ 1~ d:~ s .SUAL USUAL RESIDl:NCE--SIRCCT ~DOltrts ~srvu u~o wra~~ w ia~~a`~ ~19~ wun[ C~ir tOt+rprut[ L~rqS 2~ NAME AND NAILING ADORESS OF WFORMANT ;'pEVCE ~ ~s?~cn, .cs oe no. ~;~~~~~o 1~f 1 Ninn~ nriv~ ; e~ norothy ArR~nio ~ ..r r.~„v cn[~ 19r CITY OR TONfN ~190. COUNTY 't9c STATE ~ ~ . ~ 22 Parton Street ' Fort Ptercc~ ; St. Lucie ;Florida NP.N'bur~;h, New York ~ ~ 24 COFONER ~~.~y i2b PHYSICIAN • a..». w~ cu~~.a:.,.~e u 2 ~r. ` CO ~tfN-. ~~:,vw ~.r n~ 21o DATE SIGNED . :~~'~'(":AN~S •.r..,... . `~...~.:,....~:..°,..~..Ri ,'~~G~ ci`7~~ ~Coriin!~r7~ ~ • . ~ . `ft,~N[R'S ~:::.°r.. ~.:::::~.w.. ~..~....0.~:.. , ..'~t 'L4ls ~ ~ C~ 7 , ilrAllON 1 .I:s! •t Uu ~AT~ ~I/ ~.t.~ : Lt1. t.... ` I ~n~~~~t:i~~i:~.~n; ~1~ ne n~~.~e a~. , :~c~rvi ].l.e C~ 1 ~rriin i ]7• an~~+r w~o:R~ ~ti~~w.+w?r :ln UA/f j~ '~j~1NI OI C.(.N{~~I,(tY QI C~1~N~ (NtY IYI)AIlllit SN:N ~Ht ~u er~~ ~~~a~ lh.ltt:f Mtwtltq '.ff:fiL ,.r~~~r~~a,r 1 l.:tlljilt'3~ l~(•~lil'~.~ T~~ , i~H i-~t~ri ~l ' R-?.-7~ ,~.n - - - . _ NcY~ P~in~i;-nr, N~w Y~rk ..~>?2. A WI IN 1~~11 1 y 1 1~lt1 ~~w nw~..4 M I11~ Jw 11~ f1~ ~ a~ ;-~Y NN~N~M N ` •~I~f?}1(~~ l~~lr:~ . ~......~.w.. t/~k:I,ItJt _IItAI(C~l.i~~G ~ {`G I i:Ait • ~ M~~~:•1,~~?•nh ~sr~,r Ynrk L.~' ! PT ~ July 31, 1975 Tl IAIti 1 nfsm wA5 ~.At~i1U ,t tNnn oWr wU cRir,~ Pu~ ~wr top e u. Arm t. j } ~t ~/1r eil}tS ~iosclcrotic hcart discASC. - - • at~ io.~~R~~r a~----- - re~r rou~;nnixS..Mklr-vmai~f . ;4 a+nRVQ` r,1;L:C • ~:`.T = ei~~w~~a ~~v[ wsF t~,ft1E ~cn ~A1 r j=..... . ~,~T dF Ail ~AUSF IAI_ ~jiA[016-. ~p ~ pUE i0 . +?SCOtICNC~.OF G~ATH it~C ~tNDEBLY)lI4~CAUSE- -4a-fi. MAiM lAST. _-~a i ~~C) .y i~s... ' . , 30 PART N: DIIICR -SKN~Mw, CONOITIO.Y ~~/ul.l~ K~b Nt pf Ml~`f~ ~o ttNMU~ C~ML [nl~ r ~Yt u ut ~r~ ~unr o~ rys. nn.r~e ~1+ ~r+on~ r..a a~r ~~r~:s to~. .t. 3Lu~•t.«~..~u~nne~u~~a•~sticrr 32~..vrcv~ 32~. ev~.~wn~r~~n.s t~ ~ ~j rT. .rm~~va~~arvsr. ~~ae~w~ ;r~aLaa~.w•.v~<w~qacrq~ 1 . " . ' ~l, . No ~ 33 SPEC~FY ~c .,sy~cw[ aR n~c[ or uum s ~.•.•.w.K . •.~.•••~v.•• 3:.. I.RIURN ~T MIOR~ ~G? DATC OF WIUNY- ~o~~w ~ 36a HOUR , 'ts~,~ r~~j~l - i ~ R i tii.;URY 37~. PLACE OF INJtgtY;is • w ~ounos u~o uir ae ro~. 137~ a:r~xi r..~ ~:~:r o ••n ~~a~~en ntrr o-:w~ rcr wc~ .r ~u ~or~~ :asn - .~n.~ ro awr e~ ~aac ta~<r~ ~vtc~~ ns n w. 39. ~~...w• ' "~~G(i!1ATiON ' ~ ns.aw ui~n ~vtc~rr~tso~~a~ , . ~ ~cacs , 10. DCSCteBE HOt~ W1L'Ri OCCU{+a[Q.~.~~¦uc.a.caanr~rsaona.an~~~~w. Y1W~rIMtYYr~~~ltqRl~q[~H~ ~ I ~ . ~ - Si~TE A F. ;~STRAR - , ~ ~ . ca~n~cr?noN sTa~ i ~ This is to certif y, that the .attached is o true and correct ~ copy of the vital _~t; which is on file in this ~ ~ of~ice and of wk~~1~1•t~~ . stodian. ~ r~ cu E. w~n ~ ~ N • . ~ y: -a . ~ ~ - ~ ~ ~ ^ ";~~puty Regishar ~ 516NATUIIE OF C~r s- YE ` w? OFFICIAL TITLE - i`. 4~. • .C ~~~I `s' s , ef. - O 1 ~ r ^ :~;`ti, ~ Z Placerville. Ct~l Qryi~il~ ~ a r•:`. August 1, 1975 ~ ~LACE OF CEATIPICA ~ DATE OF CERTIFICATION . E ~Ss ~ ~ ' w~- ' • ~ ~ ~ l~~i ~ ~ . T Y y. ` . STATE OF CALIFORHIA _ ten?_ u.~.~e? Fo~r YS lff ~ DEPARTMENT OF PUBL ~ ~o«~-MO a-n aor OO os. ~ s ~ . ~ ~ ~ . d~ r ' n ~ ~ Fti~E~~ ~E ~~UKj~ F~b. . ~1,~ ~ Sj,IUV Fp~~~^M.^t ~ ~ a~v . ~ ~ ~ aoR P j t? °6 p~ i ~ oK 4 ACf 1563 ~ct ? ~ ~ ~ 31846~ ; ~ ~ ~ ~ ! r~ _ ~ _ . z 3 : "f"~~= . = `t" = ~ n~ , ~ : y~ '-~'~,c': . ..s`,:~'~y~""'~'r- 3 ~ _ ~ ~ L.ti ...c,