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HomeMy WebLinkAbout0166 ' e { ~ ~ . - .7 ~ ~ ' OHIO DEPARTMENT OF HEALTH , ~ ' ~`R' NO' DIVISION OF VITAL STATISTICS file No. ~~~~j~~ CERTlFICAT£ OF DEATH ~`R'~"~~ r DEGEASEd-NAME h?~~ JMiIIfe L+n SEX DATE OF DEATN ~.N~+~~. Diq. Yew! ~ ci.~cTOx a. sc~.~v~r~s t~aie ~u~ust z6 ~ 19~1? RACE f'~•. •~r•..•„~•• AGE- Lu~ w+oE~ ~ ~EA~ uwoE~ i owr owi[ of u~TM r.u•.r~. D+~. COUNTY OF DEATF! ~ i~Iin. Nc. ISl~iihl ti•t1/+ fn 1 D~f~ ~r.~ Mi~. Ye+'1 ~ ~ i~hite s.. 2~ s.. k. October 30 ~04 (~,vaho~a ~ C1TY. Y1tlAGE, O! lOC4TION Cf OEAtM ~ INS~CE U~Y UMITS MOS~IiAt. OR ~NE! INiillYffOl1-NAME /IJ ~N w~rfMq ~i~t ifvt/ rr/ rr~IM) j fSM 1>>n M w~I , i /F Niddlebu ~{ei hts ~es Southxe~~l ~ n~ Hos it 4 . S~I?iE OF ~IITN Ill ~M+s US.A.. ~+~rt Gi12EN Oi WItAi ~OIINIlT /~Af~~EO, NEYE~ ~~lIED. SYtV1Y1NG SfOYtt t() riJt. ~i~r ~~n/r~ wt1 ~ ~ ' WIOpwEO, OIYORCEO fS?~ti/Jl Ohio U S ~o. Narried • SOt1Al SECYl~ri NYwEt wAS OECEwsEO EvER IM Y. S. AwEO fOKES~ 11'es. w~. ~r als~r~1 yd. pre ~~era o/ stnaer! uSUAI tESIDENCE i». 1-Ol- ~m. Yes - wHERE OECEAt~ USUAL OCCUMTION IGire Ii~I r~?! f~r~ /rriss w~if ~l [~NO Oi WS~NESS OR INOIi3itY - I~vED If DEATN rvrli~j fiJt. trt~ iJ rHi?d1 ~NSTUTUTI~N, GIVE S 31m1ri ia~. N@1t York Cent d ~EADENCE tE?piE ~ES~OENCE-S~AiE CWHiY C1tY, vlllAGE O! IOCATION 1NS~DE C1tY l1MiTS SitEET /WO NYWEt ADM:SSION. (S?~ti/ )t~~?NJ ,.,Florida 1~artin ,k. Jensen 3each ~fes Lake :lanor fAME~-~lAME FirN ':~J/!t /.1!! MOTNER-YAIOEN NAME 1 i?iI .UiJJft L.~~I ailliaar Scrivena Luc Te t~eie x INFOR~IANT-NAME wultnG wDO~ESS IA~td ~r RJ.D. r~.. .n~ e. ull+tt. urt. riF/ Z ~ R. Scrivens # Lake Manor Jensen Iie ch - Z r~et i. DEATH WAS CAUSED BVs ~ Tc+ o++ir av[ c~ust ?F~ u[~ ra~. ru+o au Tw ~i~MwrE ~µt~v~wrN Z < 6iyt~ /SI`tu e1Lt t!/~' < ~ uw~~~?~ cRUSE ~ C~~li.i~r~. il ~s~. ~E AS A CONSE ~ Se~II~,,_ ~ } ~ ~~E ~I C ~rii~~ ~~rt riar 1~1 ~ fi~~r , is~~Iide ~aru /~I. pVE TO A ~ Z u~ri~t rbs i~Jer- , / _ /~i~j ~ar~t !u~ • II fAlT 11. OTMEt SIGNIfICAMT CON~ITIWafC~~/ili~~~ t~drii~ti~s t~ lydb !~N ?drq/ t~ rwiu sicr~ e~ ?nf 1(rl AUl ?St 1f tE5 r~re'~1~+p a~+wlrre.l 1 ~ !1' ~ ~r J~Irrn~u~~ trr~t Jt+fi - ~ . n. ~ ~ ~ d ACCIDENT, SUIC~DE, NOMICIDE OA1E OF INrlRY 110YR MOw INIURY OCCY~tEO lE~~~r w~urrt r~~~rry i~ ~+rr !~r ~.»t ll; atr /!1) ~ ~ O! JNOEiEWINED fS~tril)I I.~le~rb, Cq, Ym1 ~ ~ 70e. 70A. 70c. ~Ol. INJfilT Ai WOK ttACE OF 1?~IYtY Ar ~ew~. l+?ar. n?r~l. /wrm.~. IOC/Ii~ON (Sntt~ ~r N.1`.U. ~iry er rd/+~t. u+1i. t~?! W lSlrril7 )rr ~r wo/ e~~ ~/1~., rta ~S~r~i7f1 i ~o.. ~a. Y 1- CEli~flCAiION-" .N a D+~ Ym .Ne b U+~ Y~+? wt+O twiT SAw N~M/11E! 1 D~O/Ob-NOt OEwtN p~CYltEO .1t fbt )l~r~. MI~S~CUt+ AUvE ON v~Ew iME WOt IMC~1Jl) ~/rr 1ur. ~d. I~ 1 AfiFNDED iM Z// lG~/~7 +/b ) )~t.n AfiE A1A. ibr ~~if w/ } t / ~ ~.i~r/rJj~. Ire /e I - ?I~. DECEASEO f 21~. 71 ~V • ?I _ 'i~/a 71rO~~~r_ Ibt r+a~dr/ )I~lr/. CEfi1fICATiON-COlONEt- Orlb~ f+~ii !ht t:+si+~wli~w Ha~r d~+ri Tit J~ttl«I rr~ rre~~rAttllnd ~ ~l tb[ id~ r~//~r ~be i~rnfisuiq, i~ qru~~, J~+r~ .4a~tb D~~ )'e.n N~rr - _ ~rrrns/ ri~ liu ~s! /rr p tbt c.uufi) iut~l. - + . i Ji•. " r~. J?s. 3 CEltIflEt-NAME~ r~ 1/~ ~ I' 51GN~b! ~~r N/t - f SIGM~C ~ ~y Z~ , 7 22e ~ ~ 7H. ~ - MAIIING J160tE/ J V f~ ^ ~ItEEi OR~ ~ll ' SC[/ ~~O ~ ~ ~ t~e. 7~' ii~ GC C~ ~c Wt~At. CtE~u?~~C~ OAiE NMtE Of CfMETEtt Ot CtEMATOlr IOCA r+). ~dl+«. ~r ~~~+ry) fS~n/~! ` ~ ISI «l)1 . ~ • ,..,~urial ~...8 1 Woodv e ~b ' ~NAME Of EY~wWER (UG NO.1 fUHEtAt OuECTUR'S S~LHATUtE (UC. NO.) ~ m ~s. Nilliauu Te ~ ' • 1 fUNElAI filM ANO ADDtESS (S1tEEi 7r0.~ diY) IStAfE) - ~Ilf : ~ , , ~Baker._F1~R ~ * n 2Q6 ~ont Street ~ Berea Ohio ~4U17 ~ O T t CD ~Y~f~• _ '~t ~ fllt DA1E ~Elrtli ISSUEO S~GNAiY~E Oi IFlSOH ISSY~NG tEW~t OISi. NO. ~ - l ` ut.~ ~ % ~ ~0 ~I' 77 71 //l07'i7L~A~ Q~ri?)Y~,~i.j,~ ~T~i~. ~ .c ~ . - ~~t; ~ . - ~ ~ ~ ~ - - - ~ _ ~ t-~s ' - ~ ~vY ~r - _ . . . . - - . ' - - - =r - - ' ; . ~ - 1 HEA~Y ~ERT1fY :N/17 ~i1S {S AN , / ` 4 ~ _ r~,- ,.T !'n!Y OF mr ~_~?~D wf±:~u iS • ' , . - • :i - • ' . . CIERK G Y1~~01111 - . ~384~5'~~-,.~r; ~~R~f~Eo - • _ ~ . ~ s~-Z~n ~ -c ~c' , . NOV ~ ~ 44 AM e~ ~ _ ~ `,}}.;1=`iy, .r~-- • , t'X,.' - i w.r ~.,r. - - • ~ ' i ' ' ~ " ~ . ` -REG+fiwM. I/~ ~i'~'_ • - . } ~ . • ~ - ' wuli'~~ ~J ~ _ ~ . . - . . - ' ~ ~ . . ~ J . . ` i ~ Mr k0 ~ ' w ' • - " ~ a~ ` ~'i ~ • - r E ftEGfS1R/1R Of Y1TAL1"lA~LS _