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HomeMy WebLinkAbout0276 " E X H I B I T A" t;hr (~~mmnnu~r~~ltt~ r` ~u~~~ttcf~tte;riie , ~ ~ 1;~U ~ JOHN F. X. f..VOREN ~~~orcester + N~OY~CEStCT~ - 9[CR[TAN1l0~ THE COMMONW[A~.TM - • - ~ 1C~~r a To~~ wul~y ~1d re~~a) ( ~ ~ ~ ~ - ~ ~ ~ OIVIiIOM Of VITAL STATI9TIC• O (Coualy) t _ ~I }L-301 < <~IORCESTER STANDARD . . ~ cc~~r a'r~.e?~ ~ CERTIFiCATE OF DEATH R«1u~ces No , s~,~.~ . :'JORCESTER CITY HOSPITAL H2125 {~u a~„e «~~«~e ~e . Of 1M111YLM0. .~d of He~ll? \o. _ _ . _ _ _ SI. S R~rt its NA~IE inuead d slrtet and numGet) r i~• A~eat. 1 PHYSICIAN-INPORTANT ~ T~o•+s FoR CLETIS L . CP,RIBO ~ ~u aK'~~e • _ _ ~L c F:RiIFICATS J FCLL KA~tE . _ _ _ _ l ll deceaud u a muned. ~ido~ed or dn~aced remaa. R~ce aho ~sd~e name.) S. N'u ~'Neraa. Nr~, I I r OR TYPE sP~~~r W'~R) ;t_ <~K ~-,?~,5~ r.~m.~o~ R~~e.~~.:.0 8. Turner Rd, (No~Oxford, riass. ~ . s~ .---....................._..---.....r...._.. . . ut' LEATH (Gt or lowa and Statr) t ~ r .4utvG BLACK - - ~ tt .~PI'HUYED MEDICAL fERTIFlCAT6 OF DEATH YER50\AL AtiD STA7ISTIGL PARTICI'LARS I: r1 YF.N'RITER ~7 ~'~Nku~ l UATE OF AU St 2/ 1,97~ ~ SEX 10 COLOR 11 SINGLE I~n~e tAe ~ud) UEATF! ~ _ lI,~ \tARR1ED ~\IontA) (Day) fTear) PKile white N'IDAN'ED ~rried PI~'URCED H E B 1' C E K"~{ . tEaB 12.~tundea d~ceased ~jgm l'\KNOA'N 7~~~. _ , 1 ~ , ~o 1 c 19.!..._ 12 11 muned. ~ndored. w d~vac~Gladv $ C. Philbla3e l lut sa~ ~ InLLli.e oa ~~2~ 2. .0 9 7C~ deatp is said to HC$BA~iD o! ......f._. _ (G~ve madca name d.yie ~e lull) Aa~e occw~tA oo the date auted abwe. at . .d. -m. INTE~YAI (al N'IFE ot . . _ . . . . . ~ii w~dr ~l - •ETMfEEN (HusDand's namc ie full) , ~ r. hra.i l.ur.t, ut4a DEATH WAS CAL'SED BY: IllalED[ATE CAUSE ONSET A110 i: -,r:~i tir Jueau. r _gEATN 68 4 16 11 undar N ~oun b urud dett4 AI'~. riosclerotic Heart 7r.s . 13 AGE 1'nn \font6~ Days I._..:. Houn. Nineus ~ , ~ ~ ~ ' ~K• u~~ , ~ Lt . Comnan er - ret . ...u toi. ifUi~~ t~lt~ (b/ OccuW~wn . ......_.._...._.....___..._j........_....._......__... _ysa :at. . . (t~ind d~ort done durin mast d wakin~ lik) Due To IS Industry [J S. Coast Guard (e) a Sus~ness - _ e.n_ • ~rt.~~ t~ de~t4 OTHEk 264-58-5371 a: rA~ tnwi+s! dii- SIGXIFICA\T 16 Socid Security No. - ~ ~~:rn ~w (~1 CIIXI)ITIOX~ 1S BIRTHPLACE (CitY) . II]. N'as auto{ny tKriorm~d• _ . _ _ . ISute or country) ~8uth Carol ina N'Aat trs~ ton6~mea! duRnvyn~ .autOUSY . _ . . . Id \AUE OF • • _ . _ - FATHER Lonnie Cari S\\"as dixut a m~ury m an?~ ~ay rrlatrd W occupat~on ol detri.ed? rn ~v g~KTHPLAGE OF FATHER (City! _ _ 1( so. sMcily . . ~ . . . . ~ . . . . _ ~ ~s„<< « ~o„~~.,., ~~5outh Carol~ina ~ ~ . +l l0 \IAIDEti \AA1E • ~ (Si~nawrt - . ~f.D. a OF ~10THER ,~111T~1@ Hughes kobert : ~:el y, t~: ~ _ . _ - - - - . • < 21 BIRTHPLACE OF fPriat ~r e N~~e) 4 \tOTHER (City) 9 Bell evue ~ 27 _ 76 _ . . . . . _ . _ fAddressl /State alryl . Date 10.. . Ut 8T0 1I13 ~~orcester^Count ASemorial Park Paxton 2~ ~ HENE •cE IfY ~e s~,~a ~~~a- ~ d ahJyP ' b ~ _ _ . . . . _ . _ y r - • .at E Du+~d DR - . ~ kd i BEF t!t qtiit u' Platt d Burial or G~matan tGt at To.nl . . . . . _ . ~ ' - . . ~ DATE OF BUk1AL .-~~St 30 ~97..b._ <s~ nature o1 ARen~ ol Healt6 ~er) • ~ : ~ : ~ ) NA~lE OF ' *1 1 ~ .7: 7 € Fl'~ERAL DIkECTORJQ~. .~.~.4~Y~I~~ ~R 1\OTd en__~ ~ ~ • g ~ (O~cia! Desi~natwsl - Lrate ot o Permit) ~ ADDRESS3Oq . ~1IZ~OIA...~~ e ~h~QrGe.Ste~,t'~$$, ~ ~ / Icd _ . . _ 19----- - Q. ~ s ~~~a~~ Gladys C Caribo_ . . . . . _ . . _ _ _ . 8 'I~rner Road I~oxt.h .Oxford ~t ~ - ! i v.-472-070287 ~ Y . fAddras) . _ _ . _ . . . . . :'aSS • A T 'E fOPY EST: - ~ ~_F ~ ~ ~ ~ a ~ ~itp of ~orce~ter ? ~ CITY CLERK DEPARTMENT N° 10 219 ~ ~ . ~ ~ The above is a true copy of the original cemficate placcd on ~'ile ' ~ ~ office, and issued t6is dare: aUG 3 j 1g ~ ; ~5 - . ~ s ~ A Cop~. ~ltren: . , ~ Th«ms~ F. Don~iue . _ ~ . ~'t . City ~ C1er1c w r . . ; ~ ~ e~ K ~ ~l5U Pa~:f 463 _ ~ ~ . . ~ ~ ~ ~ L-~ ~92 v~c;~ z~ ~Uli~ ~ ~ ~ Sdnt I.Ut1~ CO~t! ~ ' : ~ , - _ ~ . _ - - - „ yc~ 'ta~~~„~,. .i t ~ ^-Y.~.~"f'2"'v;"`'~'~ -~s "^^~a"~r~'r~ ~ ~ s.. ' • ~~x-~'~~.,_ ~ " ~ _ . . _ _