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Home My WebLink About0092 ~ 3~U220 ; OH{O DEPARTMENT OF HEALTH , R~R. D:w. No. ` DIV{SION OF VITAL STATISTICS 5i`~ F~t` ~ p.~m,., K~R. o~.~. No. CERTIFICATE OF DEATH ReRiHrar'i No, ~ , ' DEGEASED-NAME I)n/ ~6dJlr l.u SEX ~ OATE OF DEATH ~•Ue..~fr. D.~, Yrwl R,:„u ~ 7e~wR ,7emc~.Ce i, A<,L ~ I, l976 _;i; '•R:q ~ u~d.rr,,rt.s,....iuw /1GE- [.~~r U~+OfR ~ rE~~ uN~ce ~ owr j OAIE Of ~~RiN r.~~..d., U.l, COUNTY OF DEATN ~~1w/. ~ ~(SD «rl)/ ~ir16/ ~ta~1 .N~i. UiN Norr~ ~11~w. 1ry rl p • -~/Lt.ZC se. ~ ss. sc. er~(LQ(.!/lt3~j ~(1(~ 7.. LwtL' : U , ~~it; ViIIAGE. O~ tOCAi~ON Of OEAIM INS~DE U(Y 1~M115 ~ NOSN1Al Of Ofllff INSh1Y11ON-N/~Nf IIj MN /M W~/I~ tnt ~h~N ~wd wr~~t?~ 's'•1{~,,......, Sqs BLacfabiwo/z ?c~ - - ~a4neavi.ue ~m . o ~a ' STAK-,OF •1 IM 1J/ Asf i~ II.S.A.. ~i~f UTIIfN Oi WMA1 COYNT~Y MAfRlfO. HfVft MARflEO, SU~r1Y1NG SrOUSE 11/ r~/t. ~.~~l~w wn~) ~ ~~~•,,~Qh,iv i USR W' i~'"cd~vue~'cEO ~s,.~,a~ ~ v. ~o. i i. .SOC~S CU~~TY NUM~ER W~S DEGEASED EvER U. S• AItME~ /O~CES? ' •`~1e'.~~ 1 Je +e, or r~IRp~ x+. P~e d~tti oJ iernce/ . ~7 , USUM OCNMT~ON IGirt liyJ ~J r~r! I~wt drriw{ aeu R~ND OF ~US~NESS Ot ~nOV1?Rr ~ ortiw~ li/i. ~ri~ if rrlirtJ! s~ ~ ~lvu~em~~e ~ss Hoine ~ RES~OEr+CF-SMTE COU~+Tr QT~, V~ttAGf Of ~OG(~O?+ n+S~DE C~~r lu+~TS StlEEi wr+D nUM~E• _ ~ ~ ` Oluo lafze ~a~nelvi,LLe 7ui ~ ~ ~.'~"~,v,••••~ ~.~.StIS B~nccfrb~.ovf~ %:d, FATME!-NAMf f~nl! .Nil/If Lr)I MOiNE!-MAIDEN NAME Iiql .~I~Idl~ lr~/ _ ` a ~ s ~i.l.L~m L. ~i~.:,,ce „ /~k~n. l~ainco.l.~ INFORMANT-NAME r+An~?+G AooRESS lSn~~r er KJ.U. .r~~ u!lejr. i+rr, :~pl ~ `~~o ' ~~e ~ .sl~i/£ r •o ~ f~o . ~ ?ARi OEATH WAS CAUSED BYS (fNiER ONl• ONE CAUSE Iff IINE !OR l~l. 1~1, AND ftll A~~QOa~M,?IE ~N1E~ywl , ~ ~ tETwEEn Or.SET wND DE~TM . ~ :-7 f\ , . ~ + ~ ~ . ~s. N //1rY'1i / ' ~ IMMEOMTE CAUSE lel ( ~ / ti / ~ ~ 4 tV' 7a! , ~j Coaditiowi, iJ ~w~, DuE i0, /Ojt~~~S A CONSEOUEr~CE Of~ 7 ubirb ~~vt r~~t ro S is) v`t"L Gl~~"G~i 'l.C~/I"i~~'~- ~J~~"y~ /J ~ It/f ~ - M "~'~`di1f OUE 10, O¦ AS A COwSEOYEnCE Of, . i(~hws !b• rw1~r- ~`.1~ /~is~ tirrt liif ~i 3 /A~i Il. O/NE¦ SIGMIf1UHT CONOITIONS ( o~Jitiowl s~~lrl~rli~s te Irr/b ~rf wof rrl~tNl t~rr~ jirl~ i~ ~nf ~ fIi AUtOISV If 'tES Y(If FMI/Mst (1AIIOf~f1 /O 11'ri ~~I' .r 1Nnw~ri~~ trri~ II dt+lb ` ( -t.' • M+ /C- ~ / / /J /J r Ne. )vn. , ACUDENI, SUICIOE, HOMf(IDE DATE Of le~)U~r NOUR MOW iNNItY p~CU~REO IEwIa ~~fr?I oJ ~~~ri~ ~s ~wI I~? ~rr1 ll, i:t~ Ib1 O¦ Ut+OETERru?+ED /Sp~tij~l l.New~b, fl~~, Y~o? , ,-i '`j 100. 700. tOc. ' ]00. J ~ ~ IN1UlY AT WO~K ?IACE Oi IN1V~~ Ar bowr. Inn. lhtef. /irror~. lOCwt10N - ISI.IN ~r K.(~.U. ~o.. rH) o? i~llwjt. «+rt. rr11 - - cq ~ /Spril~ )rr ~r ssl o~+n NJ~., ua lSpril)1 ~ ~ 20• 7G ~ CE~iIitCAiION.- .11~~fb Oa) 1'irr .No~lb Or~ ~~Ii? ANO IASi SAW MfM/MER ~ o~oio~o Npi DE~tM O~(uRtEO .1t ~he N~r~, ow ~ /M1iSCIAN. AU~E ON ViEMI TME lAO~, (MOU~j !ht datt, r~d, fo 1 AITENDED 1HE t0 ~ .Now/h D+) )"rn AfTf~ DEAt . Ih~ b~~f •l w~ 1 , ~J f i t~orl~/se. 1rr to c..'~ 71e. DECEASEO FROM ~ lj f 7lb. ~ 11t. ~ d I~ i~Id. ~~1~. , t~ ~6~ r+r~eli/ ibttl. CERT~iKAt~Otr-CO~ONE¦ U+tht ~ui~ eJ ~bt txr~iw~f~o• llorr /tr~b 7bt 1~ttl~A~ Mr~ prq~w~ul JuI ~ ol tbr i~J~ wad/er rbt isinri~~rie~,"iw w e0irio~, J~rfi .p~wri ` D+~ )'r~s Hoir ~ ~ at~rni/ ~w /~11ift r~J Irt to /b~ t+ruli/ Ur/tI. 7?a. M. 12b. M, ~ ff~TlilfR-HAME /T p1 Or~~~~1/ • S~Gr+AiURE UIj•~t er fidt ~ DATE S~G 0 . ~ - ~ . I o? ~ ~C• - - »e C' 1%l / Z u ~ »n . .~v G"I i--~' /~-'"7 ~ / " ' i MAtUNCi AOC~ESS~CE~I~f1ER SUfEI OR•-~f. NO. C~ Qt WI~AGE STATE l~? Sl~/ f~1G G'ML ~t~-E ~ 4-7~c' 2.~~(--~ t~'~-~-t~ c c~ 7/~ - ~U~1~A~, ~fEMAiION'DAIE NAME Of CfMf7ER~ 01 C~EMATOfT !~OCAT~ON ~ I(.~!). ~r!l~6t, ~r ~err~~/ (SbI~1 - ;;;'Q'~.~a.L ,1e A~x.14, /9~~'.~. Sf. Cence~e~cc~ ~~.a ~aine.lv~i,LLe Oluo r~wME Of EM~wlME~ IuC. r+0.1 ~uNEt/~ O~RECiOR'S S~GdAtUtE I~~C ~+0.? ,S. a~ olwian 6525'-A ' .L~iyy . ~ 4.584 fUnEtw? /~~M ANO AODIIESS ISirFET ?+0.1 It~tr~ (Si~tf1~ ll~?? S e~ 3une~uL Nvm~ 9nc. 667 /nen#vic ~R e. /~a~i,n,~iv.i..LGe li,i~o 44 • OAtE ~EC'O ~11 REGIii~ 'S SIG~+wT~lE OAiE ~f? ~i ~ uE0 SiGNA1YRE Of IE M ~SSU~wG /ft~ui peS1. t~0. ~ At +fEG. ~ ~o. ~o ~ ~ 6 , . • Lr`rs ssrr ` O~ ~ ti ~ nuL Vti - ~ _.w_ _ - ~ ~ ~ _ .