Loading...
HomeMy WebLinkAbout0994 NEW YORK STATE sT~TE s~~E NuMSi~ O~\.~..^V ~ w? ~~e«wo~~i»K:~ pEPARTMENT OF HEALTH / ~ - ; ~i ~a~54 w~asitw~~~tw CERTIFICATE OF DEATH ~ S81 - ~~Ahf~dA~ dlfMt? ~ MAYE ~~p~t ~MOOI Wt =6ER ~ DAfE O~ OEATN 3i ~fOtifl ' ~ U C I L E' . C A R~ S eN yAlt /EW~IE YONTN OAV rE4f1 ~ . i QE~ , ° ~SF,r~ ~ 8 ~ r~~ ~ 7.'.Z o ~ ; ~-3 •P~Cf MnNt( kpC~l s+wt ~ryNOSw~ruw VYM(KR~OAV ~pECfOiNTeORM_„ IVEtEMNOiU 3 AAYEOfORCC3~ ~V(NiCaY ~NOUN t ti',rq ` o~N~w:6?tG~~l NpNTN~ p~t/ ~ qOylq Y~Wt{! YDNtM WY \[AA HO •Eb IiYE9 S~EGiYWMO110A~[S ~ ~ ~ W scqwcE t •T---- ~ «llt@ 69rEU~e ~ ~ 9 ~ ~7 . ~ . a_ _ YC~MIrO N~OU11~r/INICRCNEA~S~EC1~Yi ~ ~NOSWTAIOAO~N 11~N5111U11QN ~6DIi1M~~W1A~ ~{Eff IIi?~11LM1 1 . ~y o~•" , t$u~o. Jamestown , Nut"tw.a~vic ess, ~coo~owEi ~wo_~~uKa?rE ! O ~ ~ ~ ~ ro«*M o~. ~ rw tOrrNO~ t~EwE~10ENtr qOOY ~ ~ ~ Chaut. ~ C3mu?oco. ~ W.C.A. HpSpita?1 ,~U~Mt1ENTT ' ' ' ~T'.~._~~._ ~ .G •Stw/fOF~~wtN ~OC~1~LfNOiN~~At f1YANNKSIATYSICNEG40Mt1 ~tSUNrMN6a~0U5Et«r+~fEtkvE~WDENNA~E~ ~ ~ CWtitq~UwOfIrLU COVh1R~? . - ~ []+~[VE11 M~RI~i[D ~ w~00WE0 B ~ U~ S~A • ~MU?RR~EO O dv011CE0 ~ N.Y. Gordon H. Carlson ~ L~~'.•~N ~'h.~u1Al•t.:N UP~~AUW W/~1AfS4Up IJCtth~~~l y[WI41'1 HC41KAf1UN IND~CAI[ 11:f~~[516R4DEGUM%1tEU t. _ I .11tMU N[~~N~O: ~~ti4NSiNt NUY~Eq - ~ ELEYENIMYQRSECONDAAY tOllEliE ~ - ~ Y~ ' Nomemalccr _Uvn Home 121-36-0321 ~ ~M91AlE ----*'IfOCWMIV ~1lG~OCaUTY4CMCLKtNtE1?ND6~Ct~fY~ ~r~lpKGTrORY~lU6E. ` : / 1 Q C~~11 Of ; YY~iNIN CItY Op YItIAGE UMIi87 USUAL wESI~~E ~ W ~ ~ Q~ IOMNOR E111COt t ~ YE! NO M~%E I~ OECf Of I{T ~ N. Y• ~ C~l dU t. ~ O vnuoc w ?~f ~+o. s~a~r ~oww `~EQ. E ~~,1Rf(.111NDNU4BEA ~ W, ~a 3~7 Hotivard Ave., W.B. Jamestown . ~ ~ ~ ~~M ltNSi . YiDOIE IAST . N6 FWST WOOLE 1I~5~ ! ~ ~ ~u1wE QF ~ ~ YIUOEN ~ 1. "`"'Ep Bert TOttl kins '~""ioiM ~ Florence Bedient j~ ~ ~ ~ t?ANAWEOi~hfONf~ANi , ~.sw~n~rwnooaess,~~uoe:~cooE, 14701 ~ F. j 1 - . = Gordon H. Carlson l._347 Howard Ave. W.E. Jamesto~vn NY L~ w~ ~~A6Uw:iy CAEYA7qM REMOVY Y:MiN M~ tE~11 1NilACE..~91l4~At,CREY111qNORHEMOVAI I~CIOCAiION~GTYONTONM_StAiEi F+: ` ~~~~~`~~C,, ~ ? ? 10~ 1~ 76 Sunset Hill Cemetery 71+r. of Busti, N.Y. ! L•I `l a ~X4 ~MMAMEANDACp1ES30f~VNEMLHGME . ~lY9REGISiqA1!pNNO. : r~ , - ~ ~ w~ H~ d Lind ~tneral Nome, Inc. Jamestown, N.Y. ~ 14701 ~ 01452 W 20A NAME OE , RAC __:Q~' - ~ 20Y SpN/1TURE Of FUNERAI D~ CION ~ 20C RE6~StMiION NO . L.,~ ,0 ' i # . : ' ~ 1 ~ ~ ~~y~J , , . , ' ' • N r r . ~ • j,~a,' • ~,r ~ ~..~C. ..W..' . 03192 . • , ~ {;F ! _ . J Ey ^ ' ` `I , Of11E'W M~~~-• _ ~ YOMTN O~r ~EM 7?ABU1UAlQRHE~lOYALPERMtT1S5llED ??B ypMTM OAr vE~R , ~ , _ c - , ; . - . . g ~ 30~ 7b S , ' r 1 e A ~ ~ ~ • . „ . ~ . ' ° . h~ y.......nn~ 9 30 76 L.. - rt'~ i • ` ~ r F . YA BE COI?A~1.ETE0 BY TO 9E COMPLETED 9Y ~ ~ ,~r ' ~ = ~ " ~ERTIFYINO PtWSI~tAN ONLY -~R=, CORONER OR ME~ICAL EXAMINER ONLY ~ - - - ' ~ ~ TD.A i6lT~KNCNREOGE.OtI~I~~UCCyp11E0At AOMiMEp?St9pFE+U1M~NAf~OHwNO~ INV[SttGAi~pN_INYY , ~ : 1 fpEt~QAlE41Q/`ACji~{l~0l~tipZyF - (W~Iw6MDCwTNQCCVwREDATIME TEANpvIACEANO W r~ { ~J~y'.iEg 6TATiQ'` ~--«-,~tx,_ ~tM a~ ~t~ OUE ip 1NE CAUSES STATED /C v ='a ~ ( ~ . i ~ ~ ~ ~-t O ~ , W S ONtO~ • ~ ~ ~ . . ~ _ ~ S~NEA . . .Qc~. 1.... .-.4.' MtE~ ~3,. K.C~I . . ' ~ . . _ ~ ~ 6 TNt~it ~ ~ - - - - ^ k. ~LL~ ~aJtN C iA51 SfEN4L~VE S AiON~ CEUDEAO C NOUp O WTESn;MEO . ; ~ - • ~ . V ~F ytk.}M pA~ ~iww w~«iN OA~ rEww Uwr rEU! YON?N OAr ~E~w ~ T ' ~ ~ fROw ~-1~-~~~ f~ ~ ~ ~ t ON At M. ~ ~ ~ ~ ~ ~ - s ' ' : , , ~z~ I~~ °P ~r ~ ~ ~ O N~YEUf~UI[M(MM(iPN/51CUN~iUi LN~NnNI.(NHNt» [ NP OFCUNUMLH~PH~SK~AN.IfpiNERTMJINCERTIi~ F ; - ~ ~ N~4C AMO ALON£i' E~i16ItN tA~tiSM:u~N. C:;RONE4. YEOeCK E]fAGNNF0.CC: NERSPHYSK/AM. MED~CAI DtHE'CTORf + _ 7 • G j ---1~~-`=`e"L~?'~ [o~ - - ~'Z ~e.~t Q ~l..Qt ~ . ~~~~f! : { S ccw~hwwscw~s<osr CNtCRUNIY(~ECAUSEKRI~NEFOp(A}.;9}_p?{p~Cl • Ol(IMA INIENVAI r.; t^ _ Y_ _ 0~ WEEN SE7~UFA1N ~ ' OAR IYMEpAT wUSE ~ C~~S. ~ . ~xr. rrx+c~ ~ ~ ~yh„ r~G' C ~2~' 2 ~ ! ; CAYf BiSf t0 ; ~a ~„wsw~austou +.cEOs ~ ~ INMfpAiE s ~ . C41?SE j , B~~,y ~M~ ~ STifU~l': twt ;r~ela-^L~ i KOfi4l~1MG ovc ro. o~ • co-r.EJUE!~CE QF CAUSE LAST u+~ ' ! ~"~'~~iPAp~niVinFwa~,.r1~~ `AN1GnNdIK~hS~I)M(1't.U~+S(VNip~0UT1NOi0 ?MAUipC$Yi~ pIFYfSVYEREfINWN~i:COHSiCE.'~FDIN ~ 'Q~ p(w1MSU~~.UrNflAfL070CI~USCG~YIN~NIAATt~ni YES NU ~ OETlRYINiN6TNECAItiEOFDEAI~t'7 V~ ? ~ ~ r[s wo(] ; ~ D ~?)ASCEC~r.s~fCGFN( HOM~dpE. ?ISpATFOfIWUq~' t7CH04qOF 2/DOESGRIBLMOWIMJ1iRY(K•CyR(iE0 f . ~S _ ~ SuK~OE i.nnt'ENY+MEO /[NWNO ` INJ4R~. ~ t i " lMVfS~~J,=.LIH 1 YQ4TN Q4Y ?[M ~ j . T '~-1 1 # ~ ~ ~ 1 ~ ~ ~ ~ ~ ~ ~ V . ~ ~ ~ ~ itE +KiuR~ Ai rvC~qK~~7ViACE O~ ~w~up~ M4YE • ?t~IQCJ.t1ON ~$ipEE/ ~MO. GTY Op VILI.A6E. T(riYN, CWNfr. S1A1E1 ~ rES NO ~ fACi011r.OFFrCE 8~00. ETC. ~ • ~ ~ ~ O J ~ ~ ~ ' E ' df' _ ~ _ ~ • ; ~ ! S 7 p0 f h ~pIT A~ ~ e~~~R ~i~autf~OYllt ~ ufr!- , "t~n ~ ~z 3 ~~~K ; : ~ ~ aooK 2~0 ~a~~ - •