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HomeMy WebLinkAbout0724 . ~ . ~ / THE ELKtiART COUNTY fiEALTH DEPARTMENT • `,•4"' . ~ . {J~ . ~ :tr.~~ ~ ,...r I Certify this to be a certified copy of the , ; . '•;~~~4:1:;. ~ '`'';~,below-numbered death certificate. - ~ ._yF , %y~„~~s~''~ " . )1L' - t, i I : , M~ !r,'~ m., ~ ~ j . .r ~ y, ~ ~k'•l I / / ~ / . z~i" O~LC4~f11~~~ y~v . ^ _ _ ~ Commissioner of Health Date of Issue _ ~ ' ~ ~ ~ ; ~ ~ ~ ~ r p~ 4 • V ~ ~bbr~ , ~ ~ • . ~ 1~ . • .•r• ~ ~ ~t~ I•+: ! ~'1'r1 ~ ' <7laC0 . L~UTAN~1 S?A'. . =_J~.I:~) G. . ~ ,••,,~?h". , 1 1 . . . . ~I.itc S ~°~'z . .~I,:U1(,.~L (.:.~~i.. it~.1f:. Q.~' [);:A'it[ - : ' . . .rar.o~a ~ 1 . ~ v y y~ r,,, 3 _ - - - - - - -es ~-r~' • - ~ ~~~F~ i'E<fa._sJ--t:nr~E ?~~.ar ran,o~¢~ v~r -----.-~x- -------'---i~:~El~i t[aill ~ t~, .~0~#"'~'~ ; . •u ~ R-tl>>?1 ~•n':^.?, -1.~, n.,:~;, j 1 , _ - j . . J. ~ - - ~ , ~ iyl f.;';7~iY OF~iH RACE ~<<<.E ~wst"- - u~~o~ N 1 Yt:~R `ue.n_n ~ nAY =~ilE OF C~wiN _ ~tllqfl/CAY (YEAIil~ MO3. DAYS 110UR3 MIN, ! ~~-~~Ii ~ ~MOt~7N, OAY.:.~ i) vil~ i:~~ ~ s~. 7 ~ ~sb. ~u. 4e. .,..p~ 1_:~?'3 ~ ~ :l'c~l^ _ ( IIY. WN7l, UR IUCAII(A! ~)F UEAIII ~~u•.~~e: e~rv u~~,~~3 ~ i~c::lYinl OR Vu~eR triSt~wtt0•! . t1Vtf pe t+or ~y [ntn w, e~ve >n.~ r.t wr.v r~u~~..~ N~ ~ ~•,~•rcUr aw ?tv1 . Tb- (`;C1~3{ie~~_ I~e. YC:9 7d. ~'r0';f1Ctl ~`.s_t?:)~2't2~. ~1t~;'~)~. ~::1~. 's SIAif OF ~~?TH ~1? noT in U.~.w., 'CIIIZCN OF l•.liAf CGUNIkY ~:AR~titO i~ t.EVER t1.~t.RitO (~~SUkViVR ~ SiCiII:E UFWIfF_. aiv[ ••a~~~~~ r~ruz~ = Nwls~. cOUNtwY? ` 10. ~ ~ ,„•~~,cc sl2ldl.nTltl `v. j1SA ~++a~wco fl o?voccco t~ ii.jd?_21'_i L',Vti i~c3:3:1~.=?i' . ..;co - - - . ,~wra t«~=RUT NUMBER VSUAI OCCU:AIiOtI (C.IVE Kt~iD OF P/OFK DONE CVN1~~6 TY.IT-'O OF i~1S1NE55 OQ It~ttiS~RY^~ ~ „ ~ ~H ~I~IOST OF \VO~.Kt[101IF[, E•li.Y Ii AET~REO) . .,.n~~~ 3~.t~--oS-oG~o Pc~lico ~~o~•:c ~-;b. ~i,,,i~:, ; . ~,F ~o~~ - - - - - . CtS~t'Ux_E -StAIE CVR~IY ~111Y. IG:+l~ UR UliAIiGN •ir+-,~c~ cnr ~~n~rs ~1(~:rN;auP ~ - - ~t i~~•cc~rr rr : ~:w uo~ 3 711d1t1TI'1 ~•~b. ;'il.~{}13I'~ ,iac. GU311Ci1 _ , _lia~f. ~(E?J, _ ~~~r, i~~_~ill_li' i; _ ~ _ ' SIIItI f AtiQ f:UMBER ~1-y. 'NAS OREA;fD tV[R Ily U. S. A?••,FD fG^s_tS? ~~IS ?:iS~OitttE Cit A i:~Rt.~7 % ~ (Yes, r.o. o~ ~tif•o.~n1 111 yes. 7~ve ~~vr er d~tes ~I se~v'we) } ' ?051 L. Lincol.n Av~~n~~o _ no S ~sti. .r, ~ ~ ~ i . _ - _ _ _ _ - IAl1~~R -1u~l.~E /IRSf MIhDI[ u•,r -l?aOtt;£R~t:AIUfN NAtAE ruur II~ODLE ~+~,r • ~ri~i IS. c'(t(;.`)1' A_~ ~,Oc?'~ _~I6.~ j: ~?jl;,%~ .Y~ • 3 iriipcr.wir- r~wi~E .+~niiG+:++ir ~r:iniU^:c; ~~o~ESS ~sia.:~.t on a F.o. rio . ctrr ~n :T~i-. z~r~ ~I _ . ~il'~. itn 1.t 1t 1,o;';nti ~»+~----~t.1.f~J ~»c. ~Oj~ ~a. `T.i_I1r,01_?'l~ Gn`_ii•~ 1 ~t>>~i .1~_~j~ - ~ ' ' ~ PARI 1~ UCAItI WAS l/~U:.(0 OY. IftlffQ Ol~LY pt2E CAUiE PER llNE fQR Inl. {bl. J1tiD Ic11 u rno ~.e•.~_ r..:..~:aL ' f nrnroec+ •rzr+oo;~r^+ ; I 111. . ~ . . ~ . 14M[b1At[CAV".[ ' ~~i~k~. ~ " _ ~O~' -~j r ' 10~._ 1 _~11..~: ~/~.~~.r.,~ ~~~._~~~^1Jf~ ~.:n~''~~M..~at/ y~....~.• . jl_''7 I~f~.7 t _ - J ~ j r~r~nil10~~3, 1i AN1f, OU( TO. OR A7 A COHS[OUEf143 oi: • ' w~n~ n a~v~ n~:.. ro ) _ Q ~ i. ~v...,u~w~r ~a~~•:r ~w~. ~i.) _~f"'„~~/'~ ~ ,A^;t.~/~-~~•y')~LQJ./~~y-^'~"M_ i~~ . ~ ~.I~nr~o ~~rr u~~nrN. - - - - - - ' - ~ , f ~ tU~•1 rMr.~• {.q'st ~•qs. -fq. Ow w9 A COt~•.~:~~~rT. 4i~ J k e' \11'~.[ ' " _ ' ' . ' " , S ~ 1'/~R1 il. OI11~R S~~.N~iIU?U ((X~UIIIONS CONOITIOH! CONtNt~~Uf~NO TO DEAiM BV f NOT RELAi[O TO C~USC r AUfOPSY IF YES r~~~oc~cs c^N- OIV[N M PA11T I(A~ •ES ? NO SIOCAEO 1/~ t[711tNIN0 ; ~'AUiE Of ~TH ~ - - - _ _ 19a. 14b. : 17_ r+o C 1 _ } f - ~ t CAtE 6 fiME Of OfAfN w0?+7w OAY reww Noun ~1 ~~tE S~GNED MONfN ~ DAY rEAN J ~ ~ Apr•fa. i ~97s : 3o p.M ~z~o. y 3 ~ t~. ~ iH(Sli 1A~1 S k~?AE ITYI'E QR PRINT? ' S~r,t:Alu:.E ~'F flfrS~UAN ~{'lIY. fAOE NO.__ ; ~ ~ 111 AfifHf~AHf.[ ; ~ ~ l,=,~,t i_~ II^noy Ti~ ~~c,?.~:: ~ 1~1. - - { l ~ L1.51N'p. AI~~'~ 1' t15~'.N :1T! •.~IIt.~ ! t~q p~ O. IJO ~I~Y GN IOIYN ".f ~i4 t~~' I1 1).?_ S~u Lh ~•`_i i~;h Si:~.~~:ofi, ~o:ino>>, Jncii:in:~ t~ ;~:;,r~ ; `•U~~11,!Citt:.~~~i.~(I'AO'/Al ((.r.+EIiRY,(~:~MIU~Y,iUti(~Al1k~lAE it~fJ~iION UTY0770WH'^!-•' :~~E ~ ~ , .r~-:~rn 1 y s } n ~ ?I~. t_!,.' :11, tZAb. V1_~,.~ L~ \'~:i~~, ?~~~~A~1 Ct7:'~Z. L~ ~ T • ~ r i - ~ i- r,j~ ~(7/~ ('f ~E 1YONTN, DAY. YEAR) FUttERAL Ii0lAE-t+A/.!E AtsO i DCRESS ~STRE£T ON R.i.D. NO., CITV OR TO:YH. SYATE. t~P~ ~ -,~l~~~t'i l~T ~ 197G 'lOdCY'--Citlp ~ 7 tlC . ~ ~ ~)li SO. i•i~?3 TIi1'.. ~ Co3i2 ;•1 ~ 1 , f-;~_'•.!, F . _ ~ - ~ - 11[Al:l~ r~t i1CF? -SI~.•'4iU?f, ,f pAtE QECEIVED BY LOC.SI Ir ' :1:1 OF ~ ic i ~ i: t t J' f~'/~ + ~ - _ / • ~ „ ~ ?Go. ,(f 18b. ` • t~ ' j - ' ~i~-~ jJ. ;,i i , ~ R ' Y~ ~,~i M~ ~ ~ ~f