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HomeMy WebLinkAbout2966 ~ ~ _ ~ - . ' , • _ . _ . . . ~ ~ _ _ _ 3zi~~z . OH10 DEPARTMENT OF HEALTH `~~o ~I ~ N0` DIVISION OF VITAL STATISTICB s"" F°~ N°' i ~ . ~ °'K' CERTIFICATE OF DEATH N°' `~?b OEGEASE~-NAME tiirt All~lf~ Lw SEX DATE O~ DEATM /Al~at~. Dh. Yar) ~ ~ E RACt ~s~•.•~+ A~ E w+oEe ~ rw ww~ ~ owr a?r~ or uetM 1~1..r~. Du~, GOUNTY OF DEATH ~ WLe. ~rs. [Sl~h1 ~s Inwa1 , ~ YNl 1. A. !c. 7~. ~ O C1TT. tl1~tA0E. OR ~OfA1WN Of OEATM 1 OE pT1? IIMITi MOi?ITAL QR OTNEt ItqTIiYT10f1-~NAAIE (Il !~M i~ dfi~t, ~ ~~il?) a /~~Ii~ ~N N N) ` j 7?. CI@V@ 7a 7~. STATE OF ~1lTM 1// Nt & Z1S.A., a~~~ CITIZHI Of WMA1 OOIItJitr MARt1E0, NEYE! MAIN~, S1IRVIVIlKi irO1KE /I/ rijf~ ~iwr ~~~i/t~ wt1 . . s.r.~.rJ w~oo~r~. avoeao 1S~.s:/~! ~o. soaw~ s[ounn NuwEe WAS OECEAiEO EYEt IN Y, s. wer?~ ro~tESt 71. 3-16- 3 760 IYer. r. w ots~r~/ n0 (U s~, v~ w«Zra ~1 ~mis~l usw?t t~s+~+tE ~ i.. t : 7MMERE OECEAS~ ~Al OCQtfAT10N lGr~e iisl ~1 wr! l~n l~sist ~rt KINO O~ Wf1NEit Ot INOYSTRY l1VED_ If OEAiN /j/~. trt~ i/ sttwalJ COC{7RtfD IN IMSfIM1pN GIYfi 1~. 1]~. • ~ lES1DENC6--,fiATE OOYNiY aTr. YItIAGE O! tOCAT10N INi1OE piY lIM1iS STREET D M{W~Et AQ111iSlON. ~w 9hit~ Cuyahog Brooklyn ;;;"'~"'"~'e~~ ,~.7426 Meadowbrook rwrnEe-rr~ F:.u ni;~t• t..u MornEe-.~uioEN wu~ F1..r wut• Lu ~s Andrew Gomb'ac ,a Jennie Jursinovic i INFORMANT-NAME Nu?ltING ADO=ESS (Stieu N IC.F.D. w~.. tir~ sill~e, uri, si?I " Victoria Gombac ,n 7426 Meadowbrook Brooklvn Ohio 44144 r~r DEATii WAS CAUSED BYi lENiE! ONU/ ONE GYfE IE! IINE fOt fd, r??, ~u+o ~a~ nr?ROxuu?tE ~NTERVAt • ~ e u. " ~ wMeoi~n u?usE • . c....d, ~ c~- ~ ~.u 1~.-.,- t ~ ~ ' ~ DYE TO. Ot A GONSEQYENCE Of. s C~~lhl~~i. il ssf. c. i( N~~~ ~ rjis! s~~~ riit t~ ~ Q~v ~?j tifJ , Jrr~e+/idt ssw (~1. OYE TO. Ot AS A OONiEQVENCE Of. , ~ uui~j lit rrle~• ' h++i s~re l.u ~ • ~ tART 11. OTNEt SIGl1tf1GNT CONDIiIONS_C~~Jidieia s~A!?ihffy N 1tNi 4rt ~st rrl~tal f~ s~rt~ pi~ti i~ Nf /WTOKY If YK wr~ ~~Jisp r~ssilneJ • ~Yp NQ I!t /Mf?a~j [tiff If 1t~fj i !M ~ l 116. • ACGDENT. SU1p~E, HOMlC1DE CATE Of 1lWtY ~ MOYt Now ~rwn ocNe~p /F..e~...~w• n.i.rh n. ~wr ~.rr U, it~w /81 ~ ~ O! YNOEiElMINEO lSKai171 l.~~~, D~+). }~~/sI ~ ~ 24r. 20?. 70c. 2G/. INJYRY AT MIOK tIACE Of ItWtY At Ms~. /as. th~rt. l~rt~ry. tCG?TION /Sbeet p Q.F.D. s~.. tit~ M rilbp. tf~W. iyJ j ISNM~ N~ M MI 1~[t ~//L•. N[. lSk~7~ . • ~Of. CEtTIf1GT10N- M~wti Oh Year 1M~atb Dt~ Y~r? ANC LAST SAW MIM/ME! 1 OIO/DID NOT OEATH OCqJlREO Af tit ~I~s~~t ~s MtYi1GAN: . ALIYE ON YIEW TNE WOr (HOYt) tit l~ft, a~„ f~ 1 ATTENDED 11~ TO lW~ti D~ Ya? AftER DEATN. c~ 'M ~t~~u. ~l ~ oEtt~s~u rwi? Z ~ Y 7f z' !'j ? S t~G Z f q 7 s. zi~. Oi O :i.. n. rr. ~...K,Jj,i.`t.s. CEtTIFIGTIO[i--COlONEt~ O~ tir iinu Iie tsnriari~~ H~sr ej le~ri Tir Its~Jt~t ~nu ~n~at~1 Jt~/ oj tit i~~ at/~r tie i,a~rtipt;s~, is yiaie~, Jeet~ 1W~ti Dq Yar H~ Kt~Vlfj N W/~ft YJ IOf tI t~f [~lf(1) Ifdf/. ~ YlO. M. Z~?. CERi1f1E~-~I/WE I7'rre ~r ?rst! S~GWq11RE Dtsrn ~r title DATE ZGN I~S .sH ~ - J • M S~?~.I~. M •n :k. ~ z~.. AIAIIINlt AOCREt~--CEll/fli! STlEET Ot tf.0. NO. GiY Ot 1ltllA(iE SiATE ZI? ~2~a.~ i.+ /)A1r? N,c_ r~7~ ~1 ~ ~ - ~ ~ ~ /G'~ WlIAt CtEMATIOq DATE NAME O/ CEMEiERY CREMATOtY lOGT10M f q, ri!l~st, M t~rst~1 /SI~N1 ~~"~f' f 81 s , ~,~2Feb 75 ,k_ Calvar Cemeter ,a. Clevelan Ohio = lIAME Of EMWIMEt (IIC. NO.) fWJEfA~ D OR' ,~1 YRE (tIC. NO.) ~ u_ Clarence ~iartin 5613A . - ~ ~ ` ~ 4 ~ WNERAt fllM A110 ADDtESS (STtEET NO.~~' -~%i's ' " ~ ~ ~ g ~ ' r l " ~ ' ~ : „i lSTATE) (211~ 1 { k r ZABOR FUNERAL HOMr S680•• ~ -~R 4 ^ ow1E ~Ero ~r ~ rewe~ siaN~ tE ' oJ? sKau ,6f rE~ iswina w~T oisr wo. e ~ " 1i.~ ^ ~f w. / ~ ~i ,}~y~~ V ~ 7 ~ _f~ / , K~E~ !~y,'~~ r~~ . { ? , F:~ ~ F?~E~ l,'G~7xt~ f1.?• .'.~•r ~ E ~ t~::,~. ~u.p~ _ + . ~ SZ.W~ :-•~~~~?S , ~,,,;t~ _ ~:t=_r~, • ~ ~ F. ~~~c ~ .,,t ~e'~as ~ : ~.csf~c'_s~?. ;As~; + tK . ~ tt - . : ~r~3~_ R . e ; ; . s •s~ . . . oE~(~r.' ~ r L~y ' ' {t. - 23 , •:t- ,~f #~Y'.~ r'~ i ~ . ~ J 'FS,#~~ ' . ~ ~ • ~ Nor ZO ~,,~'~.;;~~t : ; ~ . _ » 3~13"72- =A:_~?~~,.~ s~ wr-~- - - : . ~ :s _ ~ ~ - ~ 45 _~y-~~ - R ` P~2963 ~ ~ ~ c~,.s$ MY a~?s~ ~x~ sE~.t ~s BCOK ~ y 1~,~ fetG!STRAR nf VITAt STAiiSiiCa~ - _ ,y~ ~ _ - - - ; _ f r'=~ -