The URL can be used to link to this page

Home My WebLink About0058 _ - - - - - - - ~ - - - ~ - _ _ . _ - ~ - - - i •L~yNDIQ e~az~~c* - NEiY YORK STArE s~?~c s«c w~...xca ' CE~ ARTI~ENT OF HEALTH _ 2950 _ suc~E~u o~ v~Tat ~~coRVS 321433- ~ MLG•S1[R - ~ CCRTIFICATE OF DEATii . TYPE ALL EP~TRI~S OR PRINT IN PEP.!~1AhEYT E3l_ACK INK. ' ~ - -'212--~- . t. Va~e4: r.RST r.cDC:.c LwsT :r~ ~]w. n~re or oe.•~ . Dy .c.• I r ~ - 1 _.r-__-__' ~ : i ~ MA~.' I[w.AL~ v.iN_1.C~• ~'If~1~ ' ' ~ " ~l ^ r' , ~ 1 L/ _ _ ~ _ . y_~_~__ / ~ ~ , ~ ~ : : n • , - l G_1~--~-.--- ~~'~~G~ ~ 1L~ - , o -1---~ ~ ' ~ i. q,-< i..~,.~. ~ .~f. , p. ~ r. .•.,f~ ~ o~ EA VE. ~ .~~<<, e~ _ •>t~ .,.w ; ~ ~/~ti~iw.uv rvo~av. r~c.~ ~ ~v~-.r.•~,'c•~,s - .o~R9-r~'~~ . . nur10~ •t~vict j ~ ~ ~ 1[? VO •~~)~n~. 1 ^ ~ ~ ' ~ ~ ( _!-~_l ~ ~ ~.s._ _ ' r~ C'- ~L^ ~ - t^.~+ . tvvs ~~n. rowv c,rr c~ v~_i.rci~~[+. ;.rv.*~cr s•.~ ,ti ;-t. ..p..~ ~r.: ~ o~.,,• , ~,,v ~ . ' ' ` Y : . . I ~ ~ xiC. tJi ~ 1~ . , C~!'r ~w..._ •.e~ .:r ~ : .i - 'e~~',6 w0.: . ~ i '4 :.111 ' ~1~.:,~ ~S- - < <171J~ . ''.r~n~:lin c,rn~,: ,~l I.o~}~it~l I`. - ~ ~ ~ , , t i ~ : ~ c, t Z C ."1!i1 ~ ,J ~ ~ ` ~ !J~ . . _._.-_.i_ ' - , ~~.`.lAli ' • }I ~i14 1 9 ! [Cif%ffyl p^M~ '17..C1T12['~ WHAT ~ 11. M~M:T~t Sr~• ~ . ' i.r• 4'-`~:5~. -:I NIIC. u~ICiti M~:~¦ ~ ~ .a itirw~. ~ v:' ~ea•' ~ ~a ~ ~..:~TA•+ j , ' ~ ~ ~~I: ~ _ ~ ~ ~ : . 4' ~ ~ i_ _~~.__~~!~z'lit~_~. ~l_~~g~~~~~ ~~_~~.~:..~~V~~.c~~~.. ~ 1: A_~... _^;C~-'c1,'.^y ~.CYt•. iF'~+~E'~i ~ 130. R•NG O' 6-~SIhE:S OF :YDiSfaY ~ iJC. S7[~I~l lfCVw+t? MO. ~ " 1 + i ' ` ~ ~C:_ ~ \ N ` ~ ; _1- i~l~ U S ( R ; ~o - t? l - ) 7,~ _ ; . (i { a' `7G[f. _.JY"• 7G:. [JI~Y ~ /.'.7 _ ~I O? Y~ILAG[ 14E. Mr:•.'?. •Hi 14~. ."~C[7 J.Ya ~fU~•~_ I~~ ~ ~ ~ COPOu~~'1 l. 'S' ' _ f ! = j ~ : ~ ~ . r• ~•o ~ . N_,.~L~~ 1 SS A U ' ~ i ~ n. i-1,_ ;1 P.5 i r~F,~, i ,~'1 ? ; 1~' 1~ ~ .4 ~IY t ~ /,~t ~ ,a ~.--r~~s,.... •as...o-..c~•s.....-~r~ ~...•v ~ ~ r.sr ti•:OCi[ tA:T s~~f! r.n~eG~~ L~!! ' t • l' " o.~~^~ ~ ~ ~ ~ - ~ ' <<~~; ~`'1 f~ ! t _ !6A. ~v .:a..~v7'] •rwc: i .ED~1C~R1~~vG ~~^~[s3' Iiw:tuD[ 2~• COOt~ 1 ~ ! ` { i 4 j ~ ~4 ~__t ~ y r, t...1.1~ ~~t ' ~ f ~ ~ - n ~ 1~ ~ Iy y~ fi t~ s-: ~ : ,tt; , . ) ` Il ~~y~ / ' - ~P4!i'~ CfA!M K'?S C~'tSFD SI [Y[EI~ 3YCY CYf f~~JSC F[A lr~S=/~~TR7`," •1E ' •oo~~;tMATC '~hTie~11~ : ' -'7' _ ^ OE'wECw C~SC• E~ 4_, I ~ : . M i~{~TC •~~'G . ` . ' ' I- ~ i_Q l S : ~ , i. ~-i E'~~-~_!-c- - C-'r~i'~•~tf~:,..~ecJu~~rc''-~+~~uqqet--//~~((~~~' 2 ~°ai s -~~.f 'J i.-'~ a5 + CC~S[..;;C4CE Ci . . Q~~~(~ V; ~It'I~~++.'1~=~. • E 1 1~n,~Dr~:::%f~ -•.Y~. NY.f~w ' u l ; ~ I t~. S[ ltf ri.'~ - ~ ~ ~lUl E ~~::M,^,SR~r:M: _t.:~~ i~ T•J UM I'. ~ C~'i3[.~..LN ~ f _ _ _ _ _ _ ~ `F~Si.~ t~. C` {'H Si:~ - ti1 .v5 CCM'RiD~1~1'i4 1~-~{~~S? •yTOU~v~-~ae. +(S.w_w! f,~•u.M:S :'„+r~5 :lw~~_ . ~ ~ Ll.~T.+ . ~.[L~~f~_f- : _..,cC v.iFU,v O~RT I ! ?f5 ~ . . ['Co.~ +~~w. T-[ LAVSC G~ ^t• ~ ~Z~ ~ ~L: I ^fit rV~ h'~ r ~ ~ ` ~ . . . . , - ' } . t ` . • M1 • t IpA •Cf p[NT n4~C~~~ I00. ~11-" a~ ~•OG. M'JV• !(GC YOV~/ f':P IV.VM? ~1!f~..11t '[y~rw r 11• ? ~/11~[• ~N •1~ O• . 9 ' ::1 1:4:~[i[~.M { _ ~ ~ • ~i- ~ ! 7 u ~ t , . ; ' ^ { ~ ~ . y~ 1 _ ~ ~ ~-,~f~= 3 M~__' ` _ ~ _ ~ IflE ..Fr AT w-)<K' '-T 1GF. r~ACE Os ~r:-:.:' y~=..eE : 1Y~ ~OCI~T~OY / ACC1 ~ 1~'. . C~T• ' • ~ )~+lIM. ~OUMTr. ~T~T(~r . . f1 VO 1 •C!G4I. Gf{tC/ ~L[:: [sC. ~ ,J~__'__ ` -1 . ~ TO f3E COti1PL[TED BY _pR_ TO Qf ~0 +P~ETED BY _ ~ Iu ;2~ ~,aR-_ CERTIFY{NG PHY.ri1CIAN Q~NLY PA~T CORQNER OR MEOlCA4. EXAMMER aNLY 9 J~A_TO TT[ lE1T ci/ ~w• SMOALfO.C. DE1!M CC[VAy« ?t rp ini la51S O~ it9•-.ti•~ r~(S!~GATtOf~, i~. iu• ~ • i..r .•i[ •`M.= v~~CE •VO Tp '~.C ~.:Y pa~I \T_ tIV P,yfC!i L`EAT~. pCi °[n C~TC •VD CIAtC •rD L-_-i___ ~ F f~;3E• S' T[G i C;~[ TO Tw[ f~•l f5 s'1~'[' ~ 5 . ~z ~..tn _,~~c+~P a ~'L~~ ~.'0 i~7~° ~ S~~~FO. - / ¢ ,H. F~.~Sif:t.. AT ~vDF^I-~E~i~~EO C 4~5! 1E'M •l'~( B~OI ~CEC .C~~ C~ ~C~~ D_ OP~! S•GY[O i { ` C•.'w~:.4~~ ~.1- T T=~ f(~w ~f1 Y~M' ?T •FAa ~.I~YTM C~?+ Y[~v 1. ~ r i -1~_~~ . . . ~~...4 ~ 1 t 1 1 { IT M.-. i; ~a ( •PJM~! . V ~`i I + ~ ~ Iv ~ 1. ~O_ ~O ~ O~' ' , ' • r ~ -1----~.---1'--''-_'--_"i ~ ~ t-^i--- ~ ~r---- ' ~ .1_ i _ `i IG. l"CriG'v40-1YS~C~av. ~i ~ HF• 1r~Y Cfp*~f~[R E. :O~OVER': uw.]:f~AV. tF O'•.~A T~t~~~L711\/{i[R• 3 I ~ ~ ' ~1~ 1 ~`J~.~' ~ 4 = ~ ~ - - ` , ' ~ i~ ~ ~21. NI~J[ •MO ~DOP[]S n~ CFAT1~°Ce 'rw~S:C~AN, COaCttt11. ?~[7~~~L [r./~v.Y[A. COAny4•-1 0..-. ~rC~AM,f~~i~' ~O~ j*Ori ~.i 7 ~ _ ~ ~ nv l a_ ~P-~'-~PY~ ~n - n G~o f j~l ~ ~tid AvP _ - ~i~?' ~:;1~-`i t . , ~ . ; . • , Y ~f ~ ' . ~ ~12A. ~'!RIAI CN[•.~/~:16M RC~AOr11_ ewOtiTN D~? v[I~11 ~28. pIA:C OI EJR~~I. C~1(MfA110N OI~ A[V7~i 2~ YIQN 1~ A 7Q~ /T~~~~ ~ ~ LJ t-;~~p ;3~ ; ~_S'Lt- ~c= Lt1 (~E'M~~'~~a,. "f_••`sr c~ 23A. N~.~/['V~J ?7:RiS3 Of i~vhEl~/l MGMC . ~ I,Z ~ F~R•«i '~AQ. ~ ~:~-i~ w ~ i` .w. eF S.~;e t < g ~_~r~ t~1 ~~.l1~!-~'! ~ c~ c~F_ . ? - - _J,j.~4 v~ ~ .S l o cZ i p~.;. ' : --i / ` ~ ~ V 2~A !IaA•f Js f•JN[~11L O:PEC70A ~R~O Gl~A;URE Of tUKEh/~ •*CO~,~T~O7~ M'~. . l 1 ~f '.1~~•'~ • ~ F.:-_ t f~ ~ ` b '7 z~ ~ o=~QC~cN. ~ . 1 .v.. '~rsrl, 1 , ~s~. ~ ~ ~a ' ? ccis~n •.,.o~*~ o~r ?[A• •/1t •M~yatpcA~. o»n~ o~r . . - : ~ ~ 2 . F~ " , ~ _ ..G=~ ' o~ io ; : 70~ ~,~ccr-J o , 28~ zo ~ ~ ~ 1 ~ ~ # , ~ ~Q ' 0 R 246' PAGE Jo ~-Ct c C L~~OOK T. _ - - ~ ~ (S _ . _ ~ . . ~ _ . .