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HomeMy WebLinkAbout0948 i ~zs3ss OHIO DEPARTMENT OF HEALTH ~ U6 NUT w~~iE INMAROIM ~ DIViSION OF VITAI. STATISTICS HESFRVEUfOR "w u.~ r~o _ i?~MOATACOOINQ ~.N•.,.,~~., ~k. ~Q CERTIFICATE OF DEATH 'ti~~ UCf.fl)i.t~~ ~:ArdL l~.~~ 1tW4 ll~t Sfa .::.~~1„~ •~.~1~. ~t 1..~ ° - Elmore f ema le , t~!ildred E , I . , t L . _ _ _ . _ _ _ _ - - ' H1~E Y~T~tt.tl ~.~,Ms•~ T~GE-~~B.nbw UNDER 1 YEAR T liNOkR ~ UAY DAIE Oi N~RIn -t ~ ~ e.1tr~ 1. ' ` _ (~n IN.M.!\C 1 lJC~.+))! / ~~Of 1 ~l1yf ~ HO~f~i ~ ~ af/eu! t 4ni. , - ~ :61/10/1910 ,,;~.uskir.gum . white 68 _ ~x ~ ~ - ~ . - - - - - r . UT1I. VIILAGE OA Lt7CA~tONOF GEAIN NOSII~AL OR OTMER ~NSTITUT~(N1-Aa~ne~lf n..t~n~rt~-.,~a• ~vr~e ...e.,.-:r.. ~~s ~SD OH~HST. ~~o.,~r~DOA o~ ~ .~ro+i,e~,i ~ xr~: ' - Zanesville Bethesda Hospital - inpatient_ n' ---i`-- - S1ATE OP B~HiNIlf+~fu~t.SA.wa~erUTIZENOfKNATC(k/NiAY Oit~GiMOAOESCENTUq'~~~,A~r..cr~ Ge• ~a, F.y~.ati -~,i.,~. ~s~n~,at ~fC.w:'r,~,;v8?A ~ ~ *h~. Uhio ~ USA , ~9~ roAmerican - 302-~i2-1494 -r--- - - - - - ~5:.~4CREStOENtf WwSOFCEwSEOFVER~HU.SAfwEUfORCE51 ~ 'MARRIEO.NEVERMARRifO. SuRVIwNGT7C~sf.11.,~~,.:.~~_ :..~EAE~ECEASED !i'n.+, e.rw~w+.... Iry)n.~nrmr~i../s.n?el Wi00WEO.OWOftCEDrsr.r~~/yi , :~.EO IFDEATH » ]'10 ~2~ married _~,A Alan a~ • :.~~~.r~ .~c;:aREO~N - - ,S7~TtJTiON.GfJE USUAI~iCCUOAT1U1~14nr4wI..J.w~dewt~t+.v;~wps~oJrw~.yhJr.r~ewQ•rmN/ ~KtNDUiBU5~R4SYUH~yt.~~;,l~er -'FS~nE~.CE 6EiORE p • - :.:;4~55~ON ~2a. e'Qt. Housewife ~tR Domest~c ~ __._T`_~__'..__~~_._. . RESIDCNCF-STAiE ~COUNTV CIIV,VIILAGEOHLOCATION S7REE7ANPNUMbf~+ i~hStCfCI1VU~~TS . ,ISP~cd~ Yt~...~~..i Uhio ~dQuskin um ,k. Zanesville ,b 27h9 (.`lde Falls Rd no FA7HEq-NAME Feni • U~lJIt Liu ~ MOTHER-MAIDEN NAf11E f en! vNx: 1 ~u . ,S William J. Do le ~16 Maude Pierce o_ HiOp\tANT -NAME tTy?r wN1wt1 MAILING ADORESS (S7flEET OR R F.D. No ~ IC~'Y OH tc»tiYr ISiA?E~ i2~i: Alan J. Elmore 2789 Olde Falls Rd. %anesvill~, Uhio 43701 • ~ rs.nT ~ DEATH WAS CAUSED BY: ~fN7fR ONLY ONE CAUSE oER LINf fOR lal. l6I. AND Ici) Pf 7~'.t+t~: U~.SF T~ntiD ~E AT~+ ' . . • ,s ~ - ~ ` IN{MEOIATE CAUSE Ia1 S ~ ~ 1 ~ ' l. - ~ ~ ( . . . . f' C ~ : . ` . ; r DUETU.URASACONSE~tJENCEOF.~_-"__.______'__ . _ T. . . _ _ . ~ W C`.w~b:rorts. py. ..M~rh - = .o, w u..~nrJ,:u ie~ ~ ~ - ~ D~jE TO. OR AS A CONSEOUENCE OF ~ ~ ~ Z r~ rt. usrMf rRr awJo~ - - . - - - _ • 1 . l~iw;ar.uLnr ; u ~ ~ /N - ' - - ~ 7l.RTII.OT'fERSIGNif1CANTCONOIilONS~.CowJtekwcowr.IDrn~toJt~MM.rw,>~.rlarNror~.fi~l.ewwla~f/;~, 4vi:;pSV .NaSC4SEREiERAFPTUCO."aQAER ~ ~ ~ .~tr. .n. .,c;~.r~ )ri v]n . „ . .y, ` aCC.. $UtC1DE Hdl1.. UNDET.. !DATE OF INJURV ^ lICl1R H(KM1 Ih/IIHV 1XCUF~eIEU r! ni~• n -r..: ..e ~'~.r ll nnw 1 ~ ~ ~ ~ ~ ~ ° OR9EhD~NG:hYEST ;S~r,~Jvt !(ttoaM.Wy. f?a•) i T_---'~-~'~ _ i ~ ~ :a I~oe La°`= 12-°-"°-- IIiJURY AT 16t`RK OL4CE OF fN1URV AtAa~wa /u+w. i~a~t.l:ttnn. o/2'r 'IOCATI0.Y -(Sr.rrr.o R F:U + ~ •r~ .~..~r:..r~ .uv~ . ~ ~ . . - . . - . ^ - ~SxA/~ i~~s rr a~1 ':i7s.. ttt ISptcilYl { . ~Oe Z01. ' ?(4 , ro b. ComW.ud by ATTENDI PHYSiClAN ary To t,e ComWe:ea br Cononea o~y jla. To Ne fleft C! m•y krw~wleOpe.OertA pccuned ~t [M t+M. t N.x~ ?M due I*e ciu+etsl 22s. On tne Oas.s of ~.arn,ns~~o~ a'a o• .~..~,•.;at.~~. .n m~ n, r.pr~ .Sea•r, ~rc+.•r~y ax t1x t~mt.OiM ~ t lt~ttl. [y a'tO NiC! ~n17 tlue t0 tti! C.S1Y~1• S:a'tC • ' is.~..a...m nJrn • 1. /~t , c ~ ~ Y ~sK~l.~,u.. aw ner., , _ - - - DAiE S~GbE'J l~fo.. DrY.3~ari ~HOUR OF DEATH qATE S~Gt~EO i~t.:.:yt. yra,: ~„Ua CF CE~T~~ !j ~ ' 21C. ~--f ~ C ~ ~71e. w Yle. - ~ - - . - PRONWhCEDDEAD-rti7. .f~s~, tn.: ~^t•v:'v~hCFDDEAO~//,v.~ - - . . y2O.pY • AT N - hi.ME AhV aUUittSS OF CfP11F1EN IPMYSICIAN pR COHOt+ERi IryM w Priwr/ :Sn~er.+F.f" t~ n. : ir. .,.:r!:~x. .tr.a ~ Myron Powelson 2825 ~F. :v;aple Ave ZanesvillQ. ~~hio 43~01 BUNIA~, CAEMATION, OAiE HAl~IE OF CEMETERV OR CRENATORV LOCATION -i ~•:%~.:t~. ^,;:w.yn ~ fS~~~r. - ~ O ER ~SOat/~ ~ . . z~urial ~2,~ 7/25/19? ~k Memorial Park zb "Lanes~~illa. ~.~hio : , htuAE OF ENBALMER IItC. No.l tUNf Al DI 'S SIGNAT - - - - - - - - - ~ ~L. N~ 7 _ ~ ~ David L. ~iillis 6546A r~. -,~,N,...~, - . Q_` ----5795 - ~ , _ fUKER4LFYflMqi~iOAOpq~S$ ISTHEETNO.i ~ IC17V) ~;~~~E~ IZI?1 , 7 - Hik 's~`Fun'~ral` Home, Inc . 935 Forest Ave Zanesv~'~ 1e ~ ~-~i ~3701 ATF C •,i ~ R[ S ~A"$~IG/lATURE TrOAT ?E ~ 1TISS O -TS~4kA VRE ~l~ °kj~ ~ ~;:.113'~~ ~ DIS' ko • w ,.i/ y~. ~I~~ _ y~ ~ OCA HE t' ~ ii` ~ i' - It ; ~ / f . ~J/ I,. ! / ~S T. 4 v i30. ~Jt ir l~. .~i ~ ~ . ~ ~ - ~ - ' t _ i C~ ; - i S~C l I - ~ : ' ~11~;,'j~ ~ • ~ qi~ e~~ ,~E s Certif y thet I am the Regi strar of Innesv i 11 e G i ly ~r`''; - . ' e- ~ r•.' ' - : y.~ ~~~`'~d M4isY41 t~ ~and this is a true copy of the Death 1~ecord. :-ft•~ 1 ' - , ~yl- _ ~ 4P_ r~ .Y ~ _ ; ' • • , - - l,~'~2, , .,r-, s ' , • i =ir ~ ~ - : ~~L•.-^ t / ~f ; . ~ J }Z ~ - ftegistr 's SigRature ~ ~ F s~ CIE COUMTY FiA. ~ZS~6 ; ~ROCEr~ POITR,(S FK r•~CUIT COtI ~ - ~ ~ ic~c~ . AI•'r Z9 3 sz Py ~1~ _ i D 1!~ ~ ~ : . . . . . ~ _ r.,s_ . . _is 1. ~ ~ . - _ ~ ; ~ . . *~'~a"'.=a.,.~.. s ~w.~u,~,-`~'rr-.~.. - ' ~ ~.F'~'-.'~c- Y- ..c~~.. . ~~..~+iw~~