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Home My WebLink About0455 3i9661 n ~ . ; OH10 DEPARTMEN~~ OF HEALTH ~ ReR. 1Vo. S~ate Fik No. ~ ~ ~ P~~~ryR~R.~~K.No. ~~Br OIVISION OF VITAL STATISTICS ~R~~n~sNo. CERTIFICATE OF DEATH DECEASE4-NAME Fi.u AI;N/r l.,r SEX DATE OF OEATN r.W..ii, D~.~, Y.r.1 ~ ~ ~ ~~V@r • ~111~ t. 1 1 ~ RACE rb:r•, .rs.•, •.e.ic.. AGE-- Lrr~ uNO[t ~'rE~t v~wE! i o~r OAiE O? ~ItTN f.W.rr~, D.l, COUNTY GF DEATM ae.~ {~j .(hJ ~irt rmin~ Y...~ 1. 11i1iLe 3~. ~ 3~. p. i ~ ni . i. 7~. ~ . CIIr, YIILAGE, Ot lOCATION Of OEAiN INSlCE CITr )IM S I~OS~IfAt Ot OTNEt IMSi1TYT1pN...NAAIE fIJ pf er Mkr. site lh1H ~~I urrln/ j rs~rs r~ •r•~i ~ s., leld @S C StATE O? ~IRiN f1/ ~N i~ U.S.A., CITI2EN OF WMAT COYNTlY MAtt1E0, NEVE~ MARlIEO, SUlYIVIHO S/OUfE fl/ ~iJ~, tirt riwft~ r+~tl ~ ~~rtlr~l WIDpWEO, OIYORCE~ IS?~ri/)I ~1~0 U 10. I1. i SOC~AI SECUt~t~ Ntt~4E! ~ OEsEwS:~•.~.~ Y. S. A~MED iORCEif ~ ~4?ye.. are ~ue,./,vria) . ue_ 2~-Z~ NO i USVAt OCCUtAt10N /Gir~ N~l ~J M~r4 /~k lar?is~ ~~tf KINO Oi ~YSINESS O~ INOYSII~ ~ rvrti~s li/e. ~rt~ i( rtrerdl " ~ tH. ~~.O A@ U~ S' ~ lFS~DEHCE-SiAIE COYNTY di~, VIIIAGE OR IOCAt1pN INS~OE CIiY tui?Iii STREEf I?ND NU~E~ ; (S1tri/l lu M+M! 1 Ohio C181'k 11 eld ~u. fATXE!-NwME !'in1 r1ilJ/f Lnf MOiNER-1W/OEN MAM[ f~irq .~li/dlt Lnf ~ ~s. Johri ~CU~1 ' ~e. ~ INFORMANT--NAME ru~ln~G wOO~tESS IS~r~~r Jt.f'.D. r~.. tiI/ ~r iiI/~~e, u.a~. +i~) ~ ?~k8• 1~4as'th8 ~~tinun v~. ~ ~ r~?er i. DEATN WAS CA~/SEO BYs /fN~f! ONI~ QNE GI/Sf If! IINE fOR fN. 1~1. AHD fdl w~b~~~~E ~NIElvwt u. c~,(~ ~Ctil Gl.tti c/IN~ titi~.L,~ o u~a~~E c~ust • C~~Jiti~wi. iJ ~E i0. Ot AS EHCE w w~a. _i viiri ~~~t riie I• 1!1 iirs~li4t t~+i~ I~1. pV~ TO. O~ AS A CONSEQYENCE Of~ u~li~~ f4t arhr• lfiss s~w~ /irI ~ ?Ati 11. OiMER SIGN~fIGANT CONO~TIONS.C~slNi~~~ ~~~reipi.s q Jed4 iit p~ .d~~l t~ re~~ pre,~ Fs ~+s~ / I~l wYiO?S1f 1/ 1/ES rnt M+lirp i~uiJn~l ' !)"tr n N ir 1~ur.~iKi~s ~+~u ~l /e+tf tti. 7 Ih. V ~ ~CC~OEHT, SUIUOE, MO~tKtOE OATE Of 1NJURY l~OUR MOw ~NlyRr OC~uttEO ~E+rn .rro. iy~r~ iw ?rr ~r ~nt /1, i?~~ IMI O! UNOEiEtMINEO /S~ttiJ~1 I.M~~tb, Dq, Ytw1 70~. 70~. ?0~. 10d. S r?+/u~r wr wOR[ r1ACE Of ~Nlulr Ar bo.~e. /ns, ~nur. /rcaq. tOU?t~O?+ ISnrei It.t`.D. w~.. ~i?~ ~r riq+sr. u+rr. :i?1 ~ IS?rrill )~i ~r w1 •/it~ Nls.. Ht. ISKtil11 ?0~. ~ CEti1/1~AtIpN-- .M~~t~ Dq Y~r? .N~~f~ D+f )'~rr A?~D lA7i SAW NIM/MER 1 D~O/OW'HOT DEA/M O~CU!!ED .11 rbt /~/ir~, o• ~ ~N1SK1Ar~~ At1vE ON v~EW TME WO~ ~MOYl) il.t d~rr, ~wJ, u^~ 1 ~T~EHGEO TME r y0 ~ .M~~tb Dr~ ]"t~r AliER pEAtN. ~b~ ~ri~ • wf ~L- j !0 7 J ~ ~~~rlt/it. ir N ' I1~. DECEASEO FROr? 3~I~~ ~l It~. 71~.~~ M. Ik rraul~J »+1~1, ~ CE~iVtGT1pN--CORONEf: O~ 14i iriii Ib~ tz+~i~Nie~ H~rr 1~ Tbr /rr~/~a r~i p~~r~rd dr.~/ t e/ ~Lt iel~ r~J/~r i~r~uip~i~~, i~ s~ yisier, J~~16 .N~iub Da~ Yerr Herr ~ •r~r?rt/ ~Lt /i!i ed trt I~ ~i~ srattf~l rt~tt/. ~ + 27a. M. ?7~. y, ~ CE~iiilf AMf /T~ r~r ~riiu) StGNAtUR D~pet Iule OATE SIGNEO ~ ~ 23a. ~i ~~'~~~(,l~r/ !l~ ~n. ~~~~?tc f . ~-LC ~ CL4't~ :f~. ~C ?r' ~II~NG ApORESS--CE ~If1E~ ~ ~ OR R.f.O. NO. ~C~~~ t~~~~ ~ SIAIE t~ U C WR~AI, CREMI?t10N DAtE NAME W CEMEIE[r OR CIENAiOR1 IOCAt10H if), ri//i~e, ~s r~r+N~/ ISfa~) ~ ISliti 1 ~urial ,.b. 4 12 1 Fe~rncliff e~eter ~ NIU~E OF EM~A?MER +UC. HO.1 fYNERI~ pi/EC10!'S SIGNAIURE ~ (IIC. NO ~ ~ ~1 [ ~s. James E. ~s~te ?•-~.~~;ro-?n~a < /UNE~At illM ANO ADD~ESS , (Si~EEi NO.) ~Gtt) ~StAIE~ ~ Littleton ]~neral Nome n 0 ~ OAIE !FC'D {r ~EGISifAt'3 SI AiYR OAiE IElMIt IlS{IEO S~GNAtYlE p?EfSON Iuy1NG ?E~MII OIST. NO. R IOCAt • d 1 2~ J 7 . ~t. ~ ~ ' ~ y , - - :-r--^_';,-'-+~ _ , . _ . - ~ • ~ ~'his is an exact copy of the re~ottf ot des~th ~ ~ on file in the Sprin;~i~lrJ Cit~ Ne~ith Cec~t. _ ~ ~ Iss~:~U tR aCWrd~F1rF W;t;~ Sect;:;~ i~oi-F~: _ = ~ ~ ~ = = _ ~ th~ Ger.eral C e of 031ir ' ` _ 1 ~ _ l } - ~ ~i ~ ~ ~$S~S~u _ ~L _~L - _ _ ~ , ~f'~i- ~.r~ . / '~1.~, t ..N. ~3 ~ 1?•'•' . r f ~ ~ - ~~~~1 ~ _ o p . . ~ - ~ - 80~ftz4~ PACE 454 Registrar ~~,s~ ~ ' rFS4C~.bs~~r -i ~ - . . f ~ n. ~~.-..~~7 ~ ~e~',.. .r~-Y°' r`"-.