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HomeMy WebLinkAbout0091 i ~ , 325~~,~1~~ ~ ~~i OH10 DEPARTMENT OF HEALTH ~ ~ r ~~~~siON Of~' ViTAL sTATl:TiCi ~ ~ ~ ~ x°' CERTIFICATE OF DEII?TH ~`y ~~3 ' ~ DtC[Af[~-~-NAMt Nrr NWIr !.w StX OATt OI~ OlATN /Nwiy Il~ta "~rla !~R F J t.^i.~.,t.e~~srssd~a•••••+•~o ~O i~~ w~o[~ ~ niu ~ ~ wr Y rt or M~tN ~.y..+~.O.i GOUNTY OI? OtATM s~. arr. ~~uae. a~ouT10N q OEATN ~~e~ cm iu~ns Mos.~uu o. on~ ~amuno~.-.~.r ~p... w.rj... w. m.«..r...+~.~ is~. - ?~ec't _ st~n a Wm~ ~tl•« ~ us.~...... nT?:n+ a w~uT ~r.r .u?~nen. MEVe~ w?r~a. wh?w~NO ~e rN .y/e. s~•+~ •+:1.• w•.~ s~er~l - • ~ wroowlo. rS~u1/fI • ~ ~ 10. 1 ~ •op~~ sta~em Nuw[t w.i ottusw tvtt ~H u. s. ~t~eo ~oaca~ IYa, s~. ~ra4~wssl (~7s. ~w /Mn ~Jr~nierl t ttS10EMC! IH. 1~. ~ ! OECtAtlO YiWI OCANATION IGitt ~i~/ nM! /Mr lwl~ ~t~if ~l [rM0 p MIilMifi O! ~MOYiTRt ~I DEATN li t. rtl0 IM ~t 1 e?t~ rstu~I _ ~ ~ Ii~~ f . f SltOr. !li10lMCl--pAi! CWIRy pit, YILlAOE O! IOCATION t11s~f10E C11T lM :T,i' fT~l~ ANC MIwE! ali~ . 3ci~t~ Poartw~u~h rwtMts--a~M[ f:u Af:1Il. tr,~ ~+oTMe~~?urotM N~.~t run .wllr• 4w ~s. lyc~~lc Mil d ,s GaOr • F~irrow INF AIZ'T-NAME YAiIINO AOOtESS ~ ISbN/ N R.F.D...., ~b~ w ritlrp, uwe, qJ - ~s . ~ t~w .~?.t au~ wns wwsso srs rrNrrR av~r a+c uus~ n~ uNt w~ w. ~r~, rwo mi ~ru?r i ~vwi ~a~n uuw • Acat~. Nwr~ a~ooazdial intasctian - . ~2 hou~s ; an to. o~ ~s ~ oo~atoud+a a. . ~ ~1~1i1i~11. ~ A7. r1is1 sM~ rlti t• ? ~=1~Q~~iQ ~O~t ~.My~ ~ C 2 r~~ (~1• OVE TO. Of /1f A 00~4tOYENCE W: i ~Iiti• t1i a~tn• t ~ ~i~QUr~~ ' ~ w~s h~.f i~1tf ~If .r - ~ ~AfT 11. OTMER fIGNIfKAl~1 OONp~101i:~C~r/ii~r s~~tsAaif~~ t~ [r~li Mt ~~t ~tlNel t~ c~ut yni i~ ?M 1/~1 wuiO~Sr ~t ~p wn ~slirp ~~nilnd ~ ~ ~ ~ - O~ ~`fl~ altr g~N1~f.0~ ~'~ll'itr~• 11Z~N ri No.:u.~ r~r,~ N 1tir~ ~ ACCIOENT. fY1GOE.~~ Ct0[ OAiE p IM1YlIt 110u~ NOw ~N1Ut~ OCWl~EO /Eaa wrrt i+i~res ia ?wr /~r ~rrt 11. itt~ O~ 4NOtfEYUMEO fS?nit~l (IM~~?i, pr~. Y~rl ]'0~. ~Oc. Mil. ~ IN1Wr AT MIOM( NAC! W IN1WY M b~i. lu~. iMII, /etl~rl. tOCAitON /SIriN ~r R.!'.D. N.. «I) ~r rilbM. qr1l. ti11 ~ `SN~a17~~ ~r M! 1!/~.. Hr. IS~~dJf1 ~ CNT{~1(~~1~N~. M~ Qf~ YM 1~~ ~ YN~ AMO Wi SAMI MIM/N!f 1 DI~/OIp fJ~? DEA1N ~CCY~~EO ~1 I+f ~/Itft 11 MITi1GAN, Al1VE ON VIiM/ TN! p~T (1lp11l1 tM 1rN. w+. N ~ 1 AfiENOlD TII[ tp .M~~i Dir~ YtN AIiEt OfAtM. i~• •r~t ay ~ oece~ r~ 19,50 iu. Jaet. ~0~197~ JAa.10~197~ :~.Di,d 8~ 1 ks: ~'~.'~,.~r:~~,,:r.i ~ Ctf?If1~AT1pN-.CO~OMlt. O~ tM.irMb ri~ i~»~ri~s H~u ~..ii T~r tts~Iau ru p~~swsd /w/ 1![M?~ M f~f /r/ At~//if I~(~f/!I ~~M, A~1l1If QI) YM //IM M. tl~. i C!lhhN-JfA~I~ fT)M M M~! ' itG?u1 I?~t ~i~lt M1! {1MM ~ • ~ ' t3'bal~ar i11rn ~ 1t.A. ` • - . M . D. mJau.11.19'!~ ~ ww r+~ srnn o~ ~~.r.o. wo. c~rr oe v~~u?ae awre » ; i or~. at.~ . oaso ~66~ ; rw~w ~ : . . • unwt or,~waq~t,Qe awuroa ~ocw~w» ~c •rn .r+ww. « n..n~ ~.s~w ?~t P E w~w or wwwe «~c. ~+o.~ ruMEU~ Ecrori ? Twe . ~i~c wo.t a,~,~ ? 6 r,~.. ~ 1N+MA? 11w AM ~N~IM ~st~[n Mo.1 ~ut.? • ~lu~ i 1 Ci , ,y, ~ !At! _ ~ ~ ; t~1 !AR f1alIASY~ OATE ?El~tIT If1Yl0 3tGNATYR~ Of Ifill~Yp- - 4 piAl ~7 ' • 1. 1, ~ I ~ . -~r i r ~ ~ ~ ~~d k Z ~8 ~ ~ d • q~ ' ~ ~ h,~ ~ < ; ; ~ ~ p~~~'~$~.~ `^~~~'~"~~.i~r . . ~~c~~'~'.~"~~'~y r : . ~-~s~. _ ~.,.u.