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HomeMy WebLinkAbout0535 i . ~ ~ ~ 1 ~ / f 3~~.~4 ~ ~ ~ ~ ~ ~I . ~ ~ ~ I his tOPy Ii ~~s+. No.____ - Wfi1 VIRGlNIA SMIE CEPARiMENi Of HEAITH-DIVISION OF VITAI STATISTICS o be submit- s.~~.~ ~o---_ ~$3..__ CERTIfICATE OF ~EATH :~c.~ f0 t h C ECEASFD-NNIE Fi.s~ Midd'i lasi ^ SEX DAtE Of D~r1 (mon~h, day, yesr) Cora E~hel Bcan I Aug. 23, 1975 ounty Clark: _ 3. PAC[- \Yh:ee, Neqro, Amcr.un AGF- 1A51 Unde~ 1 year Und.r 1 day DAIE OF B~RiH ~~no.~ta. ( COL'NiY Cf PEA~H _ ~f~t@ plainly Indian, (spcc~ly) BIRIHOA ! usj Mys. Dayt fio~n Id:o. aay. taQ 4. r~~ ~ ~/b ~ ----I k ~ 69-~3-1898 Mon _ . It~ ~fCfllla~ Clll', TQWN, OR IOCAl10N UF DEAIt1 INSIOE CITY t11r~iS NOSI'iiAl C)C OiNfR INSTIIUIlU:1- NA4.E li( no~ in t~~na, p~rc ~trtet ~nd run,5e~) :L~,r in!: or ,t,. M~tn I~~~Yes°. M~ I~~,._ • Nlon _Gen Hs ---Q E!\'/t11C~. S.'ATi OF BfRIH 111 nut ~n CIi1ZCN UF Y.'NA1 CGU.IICT Ml,kk1E0. RfVEk l.:ARRIED, SUR\'IYinG SPOU~E (if wifq gire ma.drn ~rmcl f 1~.5.~+.. ame cwnny) ! WIDO?Y[D. OfVORC(O ;~peuly; . g. ~WV , USA i,v. marr i ed ~ C 1 arence Bean $(xiAl :[Cl7RIlY NUMB~R ~ ' USUAI OCCUPAi:ON (q~re k~nd ol Nofi d.x.e o,r.r.q KINO OF BUS.NESS C7. INDUS(FY ~ nws~ ol r:oekin Gfe, c~^n i! :cr~r[dl unk pos~master ~,~b RFSlDENCE-SU~e Covnry GtY. to~vn, oe wtatwn ~ ~~/NSiDf CIIY l{A!It5 Sereer ~nJ r~umb~r 2 Box 368 W~~ I ~n I u~. ~"f9 ~ ~ _ 14d. (~O I u~ = • ~ - ATNEA--kM1t 81Qi1ti~tACE (aure o~ ti~O1HfR-IMIUtN h~WE EiR1HFlACE ~etatc or covrury3 tountry• Ju~e S. 1~1 i 1 t I,~. WV ~,~4manda N i cho 1 as I„~. WV ---\Yas dtct~s~~ tver in ti.~ U.S. a•~ncd iortes? ~!l:iU~A~ riO~{n~,a}~ y.U~ R~cor ds AODRtS$ ~ ;Yr~, no, or i•nkrw.v:.` '{H yr5, qtve war ur J~tcs of urvlce) ~ no i»a_ ~ 1ea. Dav i d Ed9e _ I,eb. t.gtn. . k'Va G,VSE OF CEAtM (ente~ o~iy one caux per I.ne foi (e) (b!, and (c;j ~ J AV~:o•;m~re ~rierv~t 19. Pa+1 1. OEAiH ~YAS CAUSE~J BY: - I Eet .een ornN and ut.th _ IGW.EDlAiE CAUSE i+) CVA _ . ' Cond~~tons, i( sr~y, ' ~nhKh gare rice t.~ D~e to (b: _ __~~r_ebr_al.._embczl u~ _ eSove cavx (e?. _ - - - atsrinq t?re <<~+3er- ~.~u U_c <<~ _ _ ASHD--.~ _ at r_i a 1 _ f_ i-~t - - - - Ps~t 11. OiHER SIGNINCANT CO\GI11pN5: cor.d,~wos ca~f.~bv~.~g ~o orath F~~ nat rcia:cd to u~ae g~.~n ~n ~art 1(a) AUIJ.'SY Ii yee ...•r f,~•o.-~~ti lYes or ~o= ccn:~.de*ed er, oc~v~.•~.n.,~ crvie cf decs?. ~ ~o~.~O I ACC+DENi, SUICIDE, kU1. tUDE, ~ DATE OF IHJURY (n ~n~h, ~ay, yr+r} I HOVk ~ kOW IhlU2Y OCCI~~:FD ten~er natv.e of in;~ry :n pa~: 1 0: p~~~ 11. OR UN~ETERA:tNEO (+pcc~fy) i~cr~ 19: iia. 41b. ~ 21t. 'M. ~ 'tld. iN1U~I A~ wti~i. rIACE <)f ~NfUtY hl M:):AE, FA•?r, SI?:itl.f t~Y.AIIQN ;st~ete o* St.f.U. Nc , t~eY o: te.•:n, stait} (W:cifr yes ar no! ~ iAt10Rf. OFPICE B:DG.. ETC. Isc~c:lYl ~ - - - 21e. • 21i. 2:g. t s`tendcd ~f.e deccaud Irom _~r ~~~1------• to._- ~+~2~_~ J_!~ u+d list szv` the dece~sed alive on-___v! ~ JlL_ nforma• ?2. Ce~th ucruned at, 0 5Q- ~.~n- r+ c~ ~hr ctate ~:ared abcvr, an i to r'-e best o( n:y ?.•ow:c ~ae, irc~~n ehe u.~srs afa~ed. Jn contoinCd ~ :i(,tiA1URE ---lDeSree or i,iie: nDU&fSS---- - DAiE SsG~EG-~----- 1 ~ ~+{t~ tn. H~~ a ,,8-28•- i ~ +i fnis cet- ?3a H. B, Thompson, ~ ~ I 2,.- 975-- ~ . - - - - ~ - ~icatC IS COII- gUR?AL, CRElY~AiION, ltEblOYAI CEt•1E1FRY OR CkEMAj~RY NAME tOCA11pN Uit OA 1C'JYN STA7[ l~KilY) ! .;~„t~zi. zr,. bu r i a 1 I~<E. I no i an Camp __Cem 2~~. I nd i~n Camp WV _ p A 1 E ( m vn:t., d a y, ye.c 1 ~U'yE~~t KOtAE-hu1E .~WD_bDGizSS---- ;stre! o. R.F.D. f~:,., c y~~" y~Q~~j"z y P~j~~'~~~~ zsd. ~1Uy 2S, 1975 (z5.,. Wi 11 iams Home for Funerals, 770 Fai rmont Road, , f~.m ;•s-.~2 FUNERAL OlRfCiGR'S StG~A7URf DAt[ S1G::E0 ~ LATE. RICU Bv 1~1:rt i:EG. ~EGISiRAR-5 StGk:.~Uet ~ _ ~ _ _ I ( ~-3- 1975 (.~~seph i ne Joseph ; David Edge -25-1975 ~ ^ - f'. ~ ~ ~ ; ~ ; f _ . t ' RDED ~ ` ~ ~ • _ ~G~~,.'` fILE4 ~~lU ~sECQ f`~ ~ . ` ~ • `h ~ ` tFRK ss. ~uc~e co~Mtr : t ATTEST • : aoGf~ p4~Ta~5 . , < 6 N ax c~~cU~t covRj ~ W. YA. ; pF ~?ONO - .j~. .t 1~.; RE~~P~ ~Lp~F~f~ . ' i : ` ~,~,~6 ~ ~ O r ~i~-~ s ~ ~ ` t' LV ~ ~ ~ 3 ~ 3 + . - . . ~ ~ ~ - ~ .:-,,,A:~~ ~ ~ ' ~ ~ ~ ~ `ti~ 326114 ! ~ ~ ~ ~ ' • I i ~ yt ~ ~ ~ E 1 E~:~ 2~ ~ ~~4 ~ ~ ~ ~ ~ ~ ~ 1, _ i . ~ 1 ~ ; ~ ; I~ : - ~ ~ , i ~ ._._w...__:~~~