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HomeMy WebLinkAbout0868 ~ ~ ~S{ Ot~ilO DEPARTMENT OF HEALTH 1~~ Res. D~u. IYo. S~au filc I`o. Dl~~lSl~i~! ~?F YITAL STATISTICS ~ ~ _Z ~~•)~j~ ~;Pnmin ReR p~u ti~ CERTIFICATE OF DEATH R`~`~~"'~~' DECEASEU-NAME l+~u ~I~ddl~ [r» SEX pATE OF DEATH ~.?torr~.. p~~. 1'~01 I~ s~:., ' C ~ 2. 1~1 , C~ 3- 1,4, RACE R'.:vtt, w.a.o. ++~i.~.+w AGE- L.+~e Lr+DEe t~ta~ unDEt ~ o~r O~tE OF ~~~rN ~ Har:h. :1.~, COUNTY OF DEATH ~~./i~~. N:. f~p~.r~)I ~nlb (.t..n1 tlo~. Dn~ Norn ~Lw. 1~r.rr tr~TE ss 3~. 1 e'~/19/b9 ,o CUttA~:OGs CIiY, VIItAGE. O! lOlAfiON Oi OE4TM ~!~S~Of C~ir I~MiTS ~t05?iiAl Ot QTME! :h5(~Tt{hON-?:~.ME I H NOI /M WAII. ~llf If/ffl.I~Q NYNbf~I lCPttd ei or ro1 ~ re C~~'p~ ~ ra VAH CLr~"'V:.LAtID ~NTO I~TAJE PARii DIG. } - SiAtE O! SIrM ~)I ti•.t ~u C~.S..1., a~wt Oi1ZEN O~ ~MNA1 CCUN/tr MARf~fO. !~.EvE1 M~R[~FD. Su~v~V~NG SMJUSE ilt Y1~[. (~tC ~Mdll[N w~nf/ torwtr~~ W1 CEO i~0«~~)~ e FE~7dSTLVA1dZA o AES ~ o`~X.~t - DOROTHY SOC~wt SECUR~ir huM6Ei ' w~S OECEwSED EYff W U 5•trED iO~CES' 209 9791~ ~)'e~. +o. n~. r'Qwlw,{/ ~A~ A-n y_ ti~ ~a~ts of sr.saeei USU~c iESiGEVCE IZo ~7~ d~ L /LjG W ~-r°_QE DECEASEO USWL OCGuMhpN ~(,n r hwd o~ u o.t .io»t Jwr~ws n,•~~~ o! K~wD O~ WS~NESS OR ~t~OUSi[Y ^~vE6 ~f DfATM ~•~~i.~ l~~~. [~~w ir •sln~JJ ~CCURCip IN S ' Nsr,r„T~oy. c~~E ~s~ , Chase Brasa ~ Co er Ca. ~~e xES~DENCf 6EFO~E RES~DEr+CE-S?~TE CUUNiY' C~fr, viilwGE Ot IOCAi!ON INS~Ct C~Tt ltM~15 S~~EEi wND nJ~vlER ~CM~SS~ON ISO«i!~ n or ~o/ , ,.a_ OI~IIO ~.y IJ,k~ M~7+iTCR ~,..S ~6b~ Johnnycalce Ft33.~e FAtnER-NA~wE 1~rt .LI.dJlt [.~it M01NER-M~IJeN r~~taF~ 1 u~r ~1~1./!r Irit ~ „ Geox eNa ~e „ Annie Brenner INFORMANT-NAME ! M~.;~Nc AG~4fS5 ~:.t .v. N•.:. .u, o• ..::..s,. ,r..•r, r.r~ OF'FXCIAL VA R~7CO:tDS i,,, 1C701 E. Elva't. ~ Cleveland, ~hio ltl~li;b ?ARt ~EATH WAS CAUSED BV: :EivfE• Owcr ONE UUSE Ift IiNE f0~ 'e1, ier. wND rc~; ~ AF?G;~A•M,?7= .>.iE~.a: EiWEEn OtiSfi s~~p CE~Iti ea. _ r ~ IMME~IATE ~AUSE tof ~ ~ S~!'~`~L~ ~~Gj C ~ ~~::Y1« C~E t0. Oi' w5 A CONSEQU6nCE Gf Cowdiriow~: i! ~wt. . . ~ u~birb sa~• •iit ~o ;0~ ^cJ~~:~-~ ~ C~.~ ~-~~~ViT'1.^ iwwa.fi~te c.r~r ~ol. OUE TO. OR wS A COnSEQuEK~E Of ~ ^ iwh~t tbt Lwdrr- ()~r.a [dvlf 1J~1 ~ MtT ~1. OT„ER StG~jtfICANi CGNOITI NS( vR~It7ioef [oAtqBYhwt f0 drwtb br! ~at re1~I[d!o urit ptew ~e p~r! /~+l ~AlitOPS/ if rES un~ pe1.a6. .•,n~.l~.rr Or A~I ~r/ Jrlt.~+ia~~s ,~~.ir •i~ Jr..tb ' ~oa No ~oe - ACCIDENT, SWCIDE. MOM~CIDE. OATE Of ~N)URf MOUR ~eOw ~N1URt OCCURtEi~ ~Fstir q~tar~ o) i+~rry ,n p.rf ! or p~.r Il. ..~w+ i ti~ OR UNOE1E4w~!NED '~pr:rhl ~?1Gtt6, U~r, Yt~r) ~ l00 70E 70< lOd. ~ ~NIUR/ AT WOoK ?tACf OF sra:Uf. .ie h,iArr. l~.w. urtd. l~.ti.~. IOC~iiO~v ~Sh~~i or K.l.D. wo.. nt~ or ~r(l+~r. u..tr. ap/ rSD~uh ~n o. wo~ •,rb.-~ blas.. rrc. ~ly~~.1~I 4 . 20~ ~ ]Dr I : r, CERi~NCnitON- 11•..ub D~i ~1•.atb Ua+ t e.sr { I~vO MSt 5~1w M~M1NE¦ ! 1 D~DiD~O hOt ; DEaie~ OCCUiQED ir ti~e f~+~~. ou ?N~S~C~AN ~ I AIIYE ON ~ Y:EW TME SOOy~ (M'Jui) Ilrf 'J/f. /M.t, f0 QAAiTEt~DED TNE f0 ~ Nontb D.q 1"t+: AftfR Of~iM. ~~~55 y~~~. . r • 4a,r~rrsr. J~r !o DECf~SED FoCM 6/Y4/76 I~~b6/23/76 ~:d. ~~1. A M ih[ ~JYI[: fJ fl.lff~. ' ~ CE~i~f~UTIOti-CU40NER Ua !he b~us ~~t ~4~ ~..ueiw.utow Horr o~ J~~tb Tb~ Jr.eJeNt u+~ pr..Kruw.tJ Jrld oI th[ bod~ ..sJ.•.r th~+n~t~:+s..t~.w. na~ ..p:a~oes. J~rtb .~lo~rb Da~ }'t~r 1fo~rr 317.1 ~s.a . uc.:r•r~d ow tb~ J~te ..sd Jre ~o rhr uLSt~ s ~ it~rtd. S ~za ~~e <o ~3 7~ 1~' CERT~l:ft--H,?Mf r r~pe o. h~~~U S~GHAi qE ~ Drs.~r or r.N~ 4 D~tE S, r.E~ ~ j~ \ } ' .l l-. ~)o ~ C ` ~ ~ i~_~ ~ v 73b ' C ? ~ ~1.~ ~ ?3, ~v 3 ~ aa.i~vG tQDtF55--CNJiNfa St~EET OR R?A. n0. C~~r Ot v~ll~Gf ST~TE t:? 7Je Qll[1 V l:l~e1! i~L.1:~L UP-1C •U~:~l. CfEwaTipn CA:f '^~~+eE OF CEMETERT OR CREMAIOR~ lO:~t!Oh ~ltt~. uil.+ae. o. e~.rnhr ~ft~;ri - tSpc.d~! i { f z.o Bt1T~8 ~~e ~/7(j [ 7~: Western Res _r~lc+ MA~itpi=j a1 rar~eas ~hesterl~nd,0. tr~E O? Ee+~AtMft /:t~C. rv0 ! ~ fONfRAI O~iEi~O~ S S,G'UTURE i[~C ti0 , T, 7S 7)i.s ~_~~/1/1.~~ `E' i7e )1"r, ~/isl ~-f~L' ~.~~~.,1,~ _ l.,: - ~ fu~Etat F~~M ~HO •GDOESS ISiRfET ry01 J ~ !C•iT): ~ ISi~iE; !Z~t~ / / ~ ! _ _ - . ~ i~i ~ {l / r-. ~ i,-'~i ~1 iy~ ~ ~1i s ~ . ~ _ - 27 `I [ i ' T~` %~1J 1- ~Y L ~ ~ ~ 1 ' s . DATf fK ^ 6+ ~ REG~S~[A~ S S NA~upE DA:F ~FlMIi ISSUED StG~~= E Oi ?ElSOr~ ~SSU~N~~QM~T 'JISi. \O tOC} ; tF4 ? ~ _ Ql' ~ ~ ~ ti ~ 6/~3/T6 _ ~ w~.-, ~ ~ 1Scr1 . - z r. - ~ + . . - , _ ~ s~,r . ; ; . ~ ~ :+.w-~ i Z i r,':s 1 a' , . "~"eT Cct?.. , . -ti, , _ -`t ,&tL-ti. ~i6- - - _ ~ . , _ " - ~~,3 . , ~ - :;~~U txi~t ~~u+R oF v~r,~t stnns:~~s_. . ' ,