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HomeMy WebLinkAbout0134 PS-1269 ~ 3~3946 OH10 DEPARTMENT OF HEALTH s DIVISION OF VITAL STATISTICS F;~` NO. n~~ n~s. nir. rto._ Res~K•~:. xo. ~ G"~ ~ CERTIFICATE OF DEATH DEC~ASEO--NAME ti.u Alif/l~ Lu StX DATE Of OEATN ~.N~u?. p~. Ywr1 ~ ~ > R/!GE /~:n. ~.p~.....:sa AGE-- L,r u~+oE• t rE~~ ~?NOE! / DA~ OA~E Oi ~I~iN ~.W.r?, p,q, COU TY F OtATN i~/+~blit~,.iil~tf/f1 hri.i! . ~ ~rr 1. 1. ~f1 ~ ~ s.. x. X~t IL 24 • 19~ 5 r.1RtANKLIN dtt. YIIIAGE. O! IOCAtiON q OEAi11 INS~OE CI11 IIMITf MOS?IiAI OR OfNft IMSTItYf10N--NAMt f1/ p/ i~ ~it1~r. ~r~~ ifrrN+~/ wnIM1 ~ ~OI~1l~U3 a~. CARMEI, ~lEDICAI, CD~'PIIl (MaSrP) 31~iE O~ tltfM flj Mt i~ U.f.A.. ~+n~ t~T12EN Of YYMA1 ~pyNT~r ~u?l~~EO. NEVEf MI?!liED. SUrnlntlG i101qE rI~ r~f~. ii~~ *+rel ~ ~"~t~tNI~CTICU? USA to'~t~ao ~s~.~:>>~ ~l(ROP~~ 1rRISM BLAl~l8I.Zi toCUi tEd~e~Ttr ?wwEt wws oECEwsEO EvEe i?1 u. s, w~rEO foKES~ (Yfl. N. M~/~p~t1/ 7K. art ~~OH O~ t!/riR~ ~ • Usu~~ ~fs+oc~+ce ,H.0~0 - 48 ~i.. 1~0 wHEfE DECEAtEO V~~ «CtqAT10N IGI?I ~i/Ir ~J YM4I~It I~1I1• s~u k~NO W MISINESS O! INOU3Ttt t:vED_ It Ofw~11 t - ' O~CUlttO IM fi/t tsri iJ ipirtl) , Ns?~ruraN cnt ~11S~RAlt AG F eES~Df?KE ~lOfE tES~oE~KE--StAiE COUNiY dTr, v~tlnGE O! tOU1~ON ~NS~OE CrT? ~u~t1tS fieEEt u~ Nur~ta .oMis3~OM. fSNo:/s sn M r~1 ta. OHI u~. i s~. B ~ a~. MTNE~--NAilf F'i?u Afi~/!~ (r~~ A~OIMEt--alA~DfH HAML F'irtl .Villlle _ ~.ql Y IS. • tZ. Z 1 fORMANT-NAME aui n~G nooaESS ISne~t ~?1t.F.D. r~., tu~ ~r ~eflrs~, itrr~, si?) l~.. x. a~?~s~ ,~~99 v~xoK Rn. cor~rr~us, oxio 43zoq ~ ~ ~ tAti L ~A w~ ~~/~Q ~Y: sENitR ONIr pNE CAYSE fE~ UNE /p! t~). ~?t. Al/0 td) ~ ~ Z If. . J ~ i Q ~ ' ~ IMMEOIAI[ CAYfE • a ouE to, o~ ws w ca+sFOUCNCt o?: w c..s;r:.u. i/ ( ~ 2 r?is1 p~~ rii~ t~ ~ y .t,-+.-d++~tv ~u'b~ pYE f0. O~ IlS A CONSEQUENCE OI: z ~tui~~ ~ii rsler• _ l~iss ~art !rW ~i Z 1At1 11_ OTMER SIGN~f1GNT Cp/01T10NS C~r/itisu t~NdlWisS /t~lb ~rf ~~t ~tf~ld N r~rt~ j~tea p~~rf 1/~1 AU~OKr Ii ~ES r~ne'~~p ~wi/nd. 2 1?'e~ ~i ~r Ji~n~~ri~s t+~i~ ~j l~+l~ S ~ Ih. Ip. - ACCIDElIT, SU~CIDE, /IOM~C~DE OAiE Oi INJUt~ MpUR IIOw INl{!!f OCQ1lREO /Fittr wtr~t ~j ~qrt) i~ Nrt I~r ~rrl !1. ill~/ I~I _ OR YNOE1EVUNEO ISktifl/ f.V~~t~, Qr), }'eirJ ~ ~0? 70c. 100. IMJ11lY AT M1pK ?IACE Oi ~N~1!#r M M~~. 1+~~, ~~rerr. lyd~?~. tOC~LO?~ '/Sn«t ~r R.f~.U. ritl ~r ri!/R~. ~iwte. :J?/ ' !S~«d7 N~ w s~! ~~rr ill~., eu. ISl~ail)~ ~ ?01. ~ - CEtT~fKAT10N-~ /M~~16 Dr~ 1'e~r .11~~b D~~ 1'ro A?+D IwST SAw MI~?/NEt 1 WD ID Np OE~iM OCCWtEO _1t ~4• ?/ie~ ?MrS~Qrw~ AUVE ON v~Ew t iNOyt) ri~ ,/N~. w~ h 1 AttENOEO ~IIE TO - :N~st? Dr~ 1't.er AiIE! DEATM, iI• ?iit ~f ~i._ ~wseo ie~ ~ 1~ ~ ~l S ' -7 6 ~ a -7 t (o ~~a. i ~~p.r .~s~' CEli~f{U~tpa-COtONE! O~ ~8~ Nso ~f rb~ r~i~.rri~w H~~..? I~+rb Tbe Ind~wr ~.n p.o~o~~ce/ 1~+1 fk iotl o//~r ILi i~snNpti~~. i~ ~lirw~, /~~rb .~to~~b Dr~ ?"srr H~w •rsen~/ q t~e l~tr ~I /r~ b rk ~.untf~/ iuuA. - n•. • M. 27s. ~ CE~tiFE~-NAME IT~j~ ~r ~.~a/ S~ f t ~ • Ursrtt ~r Iu/t OAiE S~GNEO RICNARD Y. 7ALLD1G~t. M.D• ,~~.Ld~iUt t~c : K.D. 7 6 ~ ~?A~UMi AOGt(SS-~E~:~fiE~ STlEEt t.f.0. t~t0. C:1t • t~!tIAGE S?~TE it~ b83 a~sr BROAn s~rR~r coLU~vs, oMO ~+3~ 5 " WnAI, CtE~rAt?On DwrE n~.wiE oi GErEiEer O~ CtEw?t0~~ LOCAt~O?~ it~, r~llop, sr nr~Il1 /SfI~/ ~ T~:~~?L :.,.7-3-76 ,.~oRasr ~r?Wx vs oxlo NIWE Of Er1~AlMEt IIIC- NO.) fUNE D SI ~~i~. Np_~ a n. R~~tT Y. SHO~lA1C~t 61o~-A . _ ° R1NltAl flfY A!b ApptEiS . (SitEET Hp.) ~ (CITT) (SiA1E) ~t~rj ~ n. ~~'U?~ FUII~{AL 3~YICS 21 ST MAIN °'lGOI,UMBUS OHIO 4 2 - „ OAtE RK'O tEG "3 S~GttA ff OwtE 1flA1~ + SEGN~iqiRE pf ?EKON ~SSUING ~EfYiT OIST. NO. ,rr t ? ! 3 t! _ ' . - I ' ~~iK Ic y J ~ . •y.`~•4• ~ 2 ~ • ~I ~Y'~'-'- . ' ~ T~IS LS ~COP OF THE FFICIAL CERTIFI ' ~tI~ED _ ' ~ ? . ~ c s g~ r~.. s~ , 1.~ 1~h ~ ~r~. ' _ : ~ . ~ ~ i's' .f ~`r.tn ' xs~ , THE COLUMBUS DEPA$TMENT OF HEALTI-~,~-_~ .~~}~~-.~j . ' ~ + ~ ~ ~ • _ , . _ ~ . ; .y ~-~.1- ~'j ~ t, y " - : ' _ .~ti + ,t ~ ¢ ~~.'~i~~ J . ~1-\ ~ . . . . . _ ~ 2 ~ - ~ ~ ~ ' •~.s; ~ _ . . .~v ~ s f ~ . - . - ~ ~ . . . - :-.Rt~ ~ _ t F / ^ . ~ ~ • ~ ~a7' ' s ~ ~ " P7 s~wR nisr~rc~~ 5-- f~ h , . " ' . ~ / L[0 ANO RECORDEG LuC~E COUMSr ft~e ROCEq /OITRAS C{ EfiK C."CU~T CCU' . _ _ ~ ~ ~ ~ FEa ~6 II t 5 aH ~T~ ~ U!?RX 282 ra~~ 134 3939~6 -