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HomeMy WebLinkAbout0846 a , 4~ OH10 DEPARTMENT OF HEALTH p~ Rcs. Diu. No. c~au F~le No.'1 ~~O ~ DIVISION OF VITAL STATISTICS ; , ~,t , ~ • Primaq x~,~. u„~. ~o.-------- CERTIFICATE OF DEATH R~R;,,~l~~s xo.---`-:_-=-.--~_- . DECEASEO --P'AME lr.tl JJIr I.ru SEX DATE OF QEATH /.~t•.~rt., D.+~, Yu.J _------_Car.l Z~_ Ostr~wski-----: i_ r`al-e-- - a.9/4f]-975 RACE W'L%r., ...s.o ,~~,,;c..¦ AGE~- t~,r U'+DFt i ~Ewe Ur+DEt ~ o.~r D~tE or E~QTM r~f~.,,L, D..,, COUNTY OF DEATH iaJi..a, Nr. /Sp~ci/71 6~.rl,Ja~ I~a.r.i/ _-1fo~. D~~~ HGYII .Nl~. ~,fJl~ ~._-'1~11 - - - - so._~~ _ S°_---- - s~_ e. f t ~ 1. 0--- _ _~1~~ - - LucaS--- - - UIT, VtIIAGE, OR tOUiIGN Of OEAtM INS~Df C1T~ UM11S NOS?11A! OR OTnER It.~i~7Ui!ON - NwME (If uut d.t ~:fhr., ~irt io~tl ~~.1 r~onrdtr) rsr.~~h o. ~o~ . ~ . ~e_TQ1S.'_Sl_4._ _ _ - _ Y°g _ ia 2750 _ Sc-4t ~;•;ood ~ - - - i ` SU1E Of 6~~iH f/f n~t iti l.'.5..1., nJw~t C~t+1EN pF h'NAT COUh:TtI VUi'ED, NEvfR ~v~iR+Ep, S~:P:+Y~r.G SFO.:SF ll/ ~ilt, di+~ x:~~.!ta aa.~t/ - ~uLnh~) w~:.p+vFD, DIYOkCED ~?j~.iJ~l ~ , . !-.---P.~~~1d _ _U~,S.A` 'o ~ rr d 7~ " - ~ _I•_~_~i~. _ -~-~in_i_n,~_~_r. ~z~ki SOCU~ SfCU4~[Y hUMt~i[ ~ WAS afCEwSFD FvF! IN U. S. ASt+.fD tGRCES4 ~ . q/~ I}'ei. rio, o~ nn~eouw? ~ (I~ xs. d.ee J..!rs uf srtt~t} . :-~,,..EVCE t)e-~L7" ~S!'~~_5.`3`J_---- ~ .t76,---i10----- ~ - -`CE~SED - ~ ~ •:P :EATH USUAI OCCUiAi:ON IGnt iind oJ u or~ Juur dYrias ,ao.f of R~ND Qf EUStNESS OR t~iDUS1tY ~ ~{N ~ ~.tirrs lift. r~rr iJ refirrdJ . . ' - ~`t, Gtvf t3o.f Il ZTIE'@1__ ____i_~_ _ ^ _ t3p nOE~~l~ @r-i7ar_ vis _ .'yeEfC~E RES~DEt+CE-STA~E COUNIY ~ ~1(T, YI~~AGE O! IOUT~JN 1•+SIDE UT~ UM!tS SiaEEt R~:D :uv~Et IS~ariJ) 7ti o~ no) t . ' ~t~.0;110 ~ ~~~b r~i.1C.-iS `I'n~ t'~~O ~~e. 1'CS ta~. 775n SCO'i.~1~:~;UC~ IAIMER--NAME !in(~ .t1;dJlr /~~t T r~~!HEQ-V~~PtN Ha.Nf t~~.~~ .~I;dJlr Lit ~ '~.i'~:~1~-. . . Ai; ,s. d~hn Ostro~~~5ki ~e. Ji~dy Fa~r.ot•~ich INFORMANT NAME -y MMUNG ADCiESS ~S:~~r~ o~ K.f .p_ w~., .it~ or ~~tl..at, ~t~tr, :ip) ^~tl ~ t~ 2 5 0 S ~ t »a ajs-3tt~ _~•~Q~i'7'nt~l~~.. »e 7 _•..t:_~c~nd _ Tn7_rdn nhio 43G70 Mtf DEATN YJQS CAUScD BY: :fNJfR ONIY ONf UUS[ FfR :tvF ECf tcl, 1Di, AND !c!) R=fPJt;~.~~Q .!.iF~~~~\ . +v 'Y G'•5 O 'f~!M - -Z - ~ - - - - E. Ei w ~ ~ ia. • ` - - - _ ~ ~`./~-~Z _-t j'L~' ,~~L ~j-~f---C.~? f~t.t~..i%~:ii Cr~r~ l f i-A~ IhlMED1ATE CAUSE (el I~% 1 - - - - - - - - . - - - ~ Cae ditiowr, i/ •s~~, DUE i0, OR AS A CCr:S`OUENCE Of; (abirb jas~ rite !o (b) " ' " . _ icimr,:iJJe taL.t /I~. ~ _ _ . ~t+tia~ tbt t+nJu- G:lE 70, OR AS A CO`r5~0UE~tCE Of: 17int t+u~e l~it : . -~~~~~T~ - . _ ~i-s.~- PART 11. G.nER SiGN:fiCiNi CV•~O~T,ONSCu•r~itro~r tcnt.~l..t~ns to.'~_lf+ b.f r~,t rrlit~l ro U•JJf ~tilq fN ~~rl I!.r) F~SOPSf ~f 7ES u~~r ~•.1~•:s: . '..r1 ~ ~)'~i or nc! nr «rt~..,r.:int _n~r of....J.16 ioe ~ioe ' ' - - - i - - - ~CC~ ~i`~l. S~ UDf, NCwi~,IIF, J~iF OF iklutr HOU! tiOw ~r.iuer OCC;,c¢ED ~I~:n oJ ,..;u.~ ,n r,~.r ! c, ;-rt ll. ..~nr IM/ ~ OR U.EEiEQ!~'~;D IS~~e~~~)/ (.~iinr4, Dr~, Y~.n1 ~ ~On 1TOe lOc. ?Od. • - ` ~ - - ~ - - - ~ 1N/Ul~ AT ri0lK PIACE Of t~il'Jt~ 1! h;sar, /.,.~R, ~n~rr, !.r~n.~, ioUi~Or. /Snrrr o. K.I.D. ~o., rit~ ur ~ i!i~~r, ~t~lt, :~jl ISyraiO )ri ~01 oljct bld6., ~tt. lSpeti/fI ~a. ~a ~a . Cfttt~i~Uti6N - ~t•.arb D~~ )'r.r• .~1•..ub D~~ Y~.+r x^+D l/~St Ssvv N:iv/nN ~ e o: c~o r:or C:4TM CCC:.+~i0 .1~ rbt p/~rr, oA ~ IMtStCtAN /~:~vE ON v:Ew T~E ~GC,Y !rp~tJ i1,r J.,r~, _.,d, r~ ~ .~i-t 3~: 1 AiTEN~ED 7ME 7~ L, _ i0 ~ ~1<,r.1 D~) 1~~~. Ai7:R G;aiN. !br br~I of ++r) . ~ ~J-" J ~,Ji~.: ..ir ro ?la. aFCEASfO fROM 1~4. .~t/-~ i~ a ~'eJ~-r-~ 7tr. 7 iM_ ~hr ~..+.:~'~I ~:~rr/. , - - _ /1~- - ~ - - - _ ~ CER11FfGTION--CGQONEt ~w th~ brti~ o/ fbi ~xlnri.+d.•ioR N.us u~ d~.+J Tht St:rd~.i/ u.u pn.n~....~.td d~.i/ F~~~'~~ oJ tbt bod~ .indlot !bt iestilijitivt, i~ w~ oyiniow, dt~tb ~loafh U.a~ )'t+r llorr ~ occrnrd on !be d~lt +n! di.t to tbr ~JUrN~! ~1.+ltd, ~ 1 ~ '.tn'.. i ~ 17e. M. 1]b_ ~ i ~ ~ - CfRTIRE[--HAME /T)~t ar D~isfl S~ NATI, E+r/~ ,I pr`. ~ ~r litlt G~• ~S:' jD 1 x ~f ( ~30. l~ERV1N E~k~~~...~~,r f~A? D. ~3e l/~~~" ~~"t-~~I~ -i`"~ I»: J~~~ AtwllitvG ~D~?f! ~l W.4){~~`~~- 7~nia[~SSOEEi GR t.i.0, r+01 CIiT O~ V~LI+GE 5'A1E Ii? TOEE~O. C~fitO • 436~ t ~~e WhA~, CREMAT~ON OATE t~:AAtE Of CEMETE4ti OR C[EMAIqt1 tOCwJ~ON ii~, i,iJ~tr, o. ,•,uatyi lS~.+:el ' ~ ~S~trif~l ~ 'i 74e~tlrl a 2~e 9~~/~ ~ 1ac.__~c31.Y~L f' 4~e Ql E'~ 1..SL- ~ ~ N~w~f Of Ei+~~.IMER ~lK. HO.~ FUNEtAI i OR S S'~~fUR / (lK NQ ) ( ~ , ~s. Tho;*~~s F,_ Leon?zard 6~,49A ~s r- r . • ~ -y ; S_1_6-6 - ~ - IVNUAI F:RM ANO ?C?~fESS lSilEEi HO.) - ~C~tf) ~STATE). ^ ~It/? ~ , I,r~ki_ • ' ~ri31__-3. n p l?s~Q.,__ _ ~9 43608~--- DAiE EC'Q{~ lf~~SiR S~G~' t~RE 1E fE~~ ~1f f0 S~GN~TU~E OF /E~%'C~ JSSUiNG ?ERM~T ~D~ST.--O- . jOCA~ t[tyf 1 yy~ ~ ~ i9"I ~o . ; - _ _ _ _ -