HomeMy WebLinkAbout0586 ~~~i 3`72426
CLERK IitCU~t COU~T
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Ju~ 19 I~ 9 PN''1~
3'72426
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~ nn~n u+ tERTIffCATE OF DEA~~i _
.NENi INK E~~~~ f~q M:dd'w ~~}t SEX DATE OF TN UwMh. Y. Y~~~)
, Buster Brown ~re~or? ~ 2. Hale ! a. ~ t 2 1
./C11O"• : Rwc[-vn.H.. N.p.e wcE-u?si u,e.. i~,. u~e.. ? av OATE OF lIRTH (inor•M~. couHiv oF o~n~
~~:+~..k. tw~~ri Ie~Rn+ wr cr~«.) o.,n n~,.. ~a:~. eir. r.+.~
s, wbite f s.. ~ I~ x. e. Jul~? 4. 19~'I Grrenbrier _
CIiY. 101MN, pit IOCATION OF pEl1iH INSIOf GIIY 11M41S HOSPIiAL OR 01HER INS ITUiION-NAME UI ~t ~~~r, q~ sueet rwmba-~-
rnid~nC~ i (3PK~N 1~ a no)
~f m. Fairloa { ZIo ~a. areenbrier Valle~, 8osvital
STATE Oi 61RiH (i( np1 in C~TIZEN Of WNAT COUNiRY MARt1ED, NEVER MARRIEQ, SURYIVIlMs lN wH~. O~ ~
qry• V•S,A-. wrw~ o~Mry) I WIDOWED. DIVORCf~ lsPKifr)
~~r• ~.Ye~t Virgini,a I 9. O.S.A. ~ ~o, Married Gl vs Hoylman
SOCIAI SECURIiY MlA~{ER USUAI OCCUiAT10N (9~ 4' of wwlt dw~e ~0 KIND ~ WSINESS OR IHOUS[RY
nwat o1 wwtiiq lii~. ~vx? if rN~td~ j
265-O1-6750 I 13i. Cad ter ~ 8esort Hotel ~
RESI E-SNN Gounly Chy, towA, a loctlbn iNSIDE CITY UIYUiS SueH and nwnba 1
f.o.citr rea o. no)
ii. Ya: tireeabrier „~ihite Sulphur Springs 1~.a. 2ee 211 0~ o tre t;
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i H E R- M A I D EH NAME ll~ry~
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~s. Jawes Franklin t~re f Y. Ya. I~s.. Bose Ellea Hurndoa Y a
Was decMad avt. in tAe U.S, a~a~ed tacea? 1 -SIGNAIURE ADORfSS ~1 O~COIIII@~ Str•
(Yq. no. or vntnow~ (lf yes piw wN o~ da~es of ravic~) ,
Yes I~,b. V. M. II ~a. W~,ite Sul ur S W.
GUSE Of DEIIiM (uitK onfy oe~ cwis v~ ~.fw (p~, ~nd (cI) • ^ Appoa:~wc inlerval
u '1 ~ bM?veen onae~ de~th
19. ?at l DEATM WAS CAtlSEO 611: ' /
IMMEOIATE CAUSf (~1 f 'f-~ ~~'~~12.-fi-.G.+?T-,.~ 1 jl.Y;?+`•?-'
Candilioe?a. H +rry. f ~ ~
wAteh qav~ ~t+~ a Ou~ a(bl
•bov~ cauk ~a1_
st~tr~p IM wa~r
h?~0 cwk tad. Dw to (d.-
?~rt 11. OiMER SIGNIFlGWT CON~I710N5: cad.tioes contr~wq a deai~ bu1 nM re4ud a~au+~ q~n b w~ 1(~) AUIOPSY If y~s wen find'a+ps
(ris or no) conside*ed in del~rminirp .
~ ~ ~Qb. of dsath
ACt~DEIiT. SU~CI~E, NOMICIDE, ~ ~AiE OF INJURY (nanfh, d~r, Y~) ~ HWR H4W INIURY OCCURREO t~N titurs o~ iniury F~*~ ~ a~ W~ ~
o~ t~Ew~ur~o (wK+h) ~v1
~t~, 216. 21u All 2Id.
~ 1lUURY R~ MIO~K PIACf OF INIUAY Ai HOME. FARM, STREEf.I lOCA110N (qre~t a R.F.D. No., c:y or bwn, st~te) .
(~ei(r yp w e~ ~ FACiO~Y. OifICE dLOG.. EiC. (~pecifr)
21~. 21i. 21
! 1 atlu~deA ~M dadwsed f~ ~4 a ~ + 5 ~0 8~2~7~ ~nd 4s1 ~aw Me dece~s~d ~live aiL ~'~"75 ~
~ ' 2Z. De~d~•~ ~ • q~~~ dr~e st~led ~bove: ~ni w tAe beu oi n~y knowledp~. irom the cw~es a~ted.
SIGNAT / (~1~ a~tk1 AOD~ESS DATE SIGNED
i l_l./ / ;%~~`j.~
j Rancavert~ , l~l. Va. I~ 8-7-75 _
~~'CRfAAAT10N, R~AI GENtE1ERY O! CRfAtAiORY-NAlME LOGitON ' CITY OR 10WN STATE _
z... Bwriai 1 i z.e.Eose~woa eesete I z.~ visbur Y.s vir -
pATE ;mo:+tl+~~ay. reu) fllNE~I1l MOINE-H/1ME AtiD ADDRESS ee or R.F. IJo., cifp or awn, s~aa. :lP) .
~loua~ain Avenue
~,~ngust ~t~ 19'j5 ~ u~enklin Funeral Hame Yhite Sulphur Sprinas, M. `la. 2498.~`_ ,
FUNE DIkEC104'S GNATURE DAIE SIGNED DATE RK'O !Y LOCAL R=G. ~EGIS RA~~~ 7URE '
~ s • ( 15c ~`~S 1 26~. ~ / ~ ~~J ' a
- I hereby certify that the above is a true photo-
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. ~ ' ~ ' static (photographic) copy of a record filed with
- . ; ~ . .
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~ ~t; ?;--.,ti~ . the Division of Vital Statistics, West Virginia
. `~'~y State Department of Health, Charleston, West
: - . : . ~ S Virginia. ' ;
' : ~ ~ ; r~,' - ~ Witness my hand and seal this ~wenty_seventh ~
" f day of Au st . 1975 ~
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~ • ''~~p'.~Z'1~~-~~ ~ ' ~
a~ N. H. Dyer, M. D. , M. H. , State Regiatrar ~
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0 R 2~1 9~GE 506 ~
600K ~
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