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HomeMy WebLinkAbout0045 ~ 4 I846 ` ~ t.F.~?k(.IA 1>f.l'AK7VCNTi)! Hl!!.1AN kl:ti~~l kl'k:J , V17AL kFCURI)S UNIT ~ CERTIFICA•rc oF ~~~n•r~i S,alr F,~~,~. _ _ _ _ (i')'1't' OH 1'Rl:~'T) ' ~ HikTH NO. • Custod~~n•s NO: _ • ; ~1n?aE OF - - Fus ? - ----M~aA~ej ~ (uft) - - Y. DATQ jMO~tn) (:~av) (VC•i) tiF CEASEO . OF OEATH ~ S' 028 - ' ~ - - :~~~nCE OF DE ounty) UAL ES~DENCEI.:~C~JJtCfJ1'A~ntC.Il.nit~i~i~u~.~.+~•~cew~ou.u..,•~~wnl: ~ ~ i - --'vY - - - State _ ~="`i `^'v`~t ~CountY _ _ - - - C~ly w uwn In CNY Limib~ Lenyt~ ot St~Y - . In GIYZ~` Lenoth of stay ~V~ (~n thii PIaCl) ~Vtf ~~NO (~n tAn D~~<!) C~ty Or _~'o.~• -row~~~. ' - . Na~~ Hos7~tituUOn-- i L~nytn otitsY St~est Aadress o~ R. and Box No. . ,~k~r"~V~ ~iT .Q~ ~~•O•~•--- -_J~L' i .•,EX 6.RA E 7. BI T 1PlA 5: ~c ;~ce,.i:~~. Gtire~ ol what IS. IS ~S~~NCE ON ~~6. gUR1AL Ds1t ! cou I~y~ FARM? EMOVAL s ~ ~ ~I~Q.,~~a . (]Ves o ~~RENATION e t~t. t E ~ BIitTH 9. AC.E (~n year 11 unO yca 1 unde? N Hrs. ame oi ~r ' Loci on (City or ow~ (~ounty) (St~tej' 1as1 Dnthday) MoMn Osys Hows Mins. I I - tQ o~~ -?1 ~-1--- -1 ~il~~tc.,f ~hti!~_~l _.(1,t_i_~__ . . •~-~~a,~ 5 - }`MARRIE ~ VER MARRIEO II tnanieC o~ W~do eA o~ upa~ated. 1~. EMBALME~~NAME L~cens! NumOer '::~DOWEO ~DIVORCEO l ~ '?+R' p1 u . , • 1/ `J • • ?SEPARATEO ~.GfU - -L.V~ ~ _ {!V _ - ~ _~~O ~ Y - - ' - - - - - ; 1 '~SUAI OCCtlPATION (G~re k~nC o1 wo~k O 01 @us~ness or Intl try J8. f UNE RAL MO? e uj~nq oil wor ~ng bje even ~ ti~ ~ ~ C ~ t~~c~'-~~~!s~ - - - --?n2=- - - _ ' Y. AS OECEAS D VER IN U_5. ARMEO FORCES~ Social 5ccwdy No. 39. FUN~RAL HOME AODRE55 {,~ei, no, or unknowD) ~11 ytSaive wa~ Or O~iti O1 Serv~t!) ~ ' ' -;~S Y-- 1----~.t,Z~.r~__ _--o~-?-Q~~Sy-- - ~-3~o-~°pw_~?- . v ~ ATtf]R's ~1E ~ •20. INf RMANT Relatfunsh~p - ---i~-?~---- - - ~ " - - 1: !~UtHER'S • IDENNAM 1.iNF~~T'SA D - - . _ - - - - ' - - - - ~ _ . - . r.~,!SE O~DEATH~n ~y one cause Der I.neTor (a),(b), anA(c). PlEAS RINfi n(eiva~ between bo Aoi Rrriie in Yh~i 3nace onset anO deatn 1_ ~:+NT 1. DEATN WAS CAUSED BV: ~ ' I Ib1MEOlATE CAUSE ~~?____~r91~h1~~?.Xocardial_in~c_lY_Ct _ _L_ 2. 3. ~ , ~~!~c~:,s ~t any, DUE TO (bl--- , i ~~::e.enseto - - 5:--- 6.---- ~ .e caux (a). : .~q ine untler- ~ i . ; a~s~ ~,s~. ouE To - - - - - "~~:,H i 11. Other sign~l~cant Condit~onS CoMribut~ng to death bu! not relaled to tne tenn~na~ O~seaae cond~iwn g~ren ~n Part 1(a). 23. AU7UPSV t natural - ~ ~Yts~NO _ it CPF. RAf10N ~'ERFOR?dEO- 2ai. DAiE Of ~ 24~. CONDITIatV~ fOR~WNI~fi O~CIZ{?~1~N 1N1SS~PEf~F8Rb1~D . ` '~:-~~~c~~ttt Uems 26~i a~d 24•D - OPERATION ` , = + ___~2G.-3iGNATUiFEOFt~NV3~~17iN' - --------------i3e9~eeorTlTe- : t 1 ~ r~ertby tl~tity t~at 1 atttndetl the deceased trOm : i . , . to . 19 thst 1 ~ast saw tAe deccased - - - - : ~ l~i7aiess ale 5~9neC ~ _ .e or, _ _ _ . 19 .and that ~ ~ ~f ~~ccune0 at .m. 1rom the Causes bnd tt~e date statetl abov!_ I i CnRONER - ti1£DICAL EXAMINER - PHYSICIAN ,r ~ ~ % ~ ~ ; ACCIDENT ~~~e ol In~ury (t.g. in or about In~ury Occuned (C~ty or Town) (County? (State) T~me (MOnl~j (Wy) (Yea~) (NOUr) ~ SUICIOE ?home, farm, fadory, street ? While at wotk Injury ! ~ r~OMICIUE ~o~~~~e b~0g., e1cJ ?Not while a1 work I i .!:.,w AtA 1n~ury occurs - ~ ! - - - ~ ~f - . ~ ~ f E RFCE~IVED TCoruner' gnature - . Hdd~ess ~1~ . ~~~8~~~~fi 5~. Date S~9~eC ; v C. NON R ' _ - Decatur, Ga. 3fi030 5/31/7fi w ~ , _ _ 1'_ $ ~ ! J ~ ' - - Date S~gned ~<.7 E RECEtVED S RAR'5 SIGNATUR AAtlress f , ! ~:CAL REGISTRA ` ~ J ` ~ n ~i ~ J • J /Q ~ J ~ - _ - - ~ : 3903 IR~. 676) - . ~~~IE ~Q~N~Y ~EA ; _ _ _ - - R_~'"-" ~!1~'R~!' "CERTIFICATE OF RECORD" Cf~;.~ -i /1 ~ • ~ .~~,L~ ~ "This is an exact copy of. the death certificate received $~c t8 43 QH ~ for filing in Dekalb County, Georgia." ` ~g ~ r - ' ~ ~ 418469 ~ ) ; / ~ Signed bY ~~3 ~ - ~ ~ ~ I.~cal ~u o~ian ' ' Office ~ Local Custodian ~ ; '~ekalb. ounty - - ~ ; - _ : . Da te ~ ~ : r ...;s~.... ' ~ a 1 A 81'7'7 }~arold H. Goldn'1pn ; a.TTp~NEY-AT-lJ1W . ~ 2 9 5. Fsd~rol Hwy. 3 ~ : .t Luti~, Fb. 33452 - a ~ ~ ~~95 ~~S r F K . . ~ ~ . : . - . _ . .~v~ v ~ ac ~ . ~ . _ " dg:~."., . :,~v . _ ' . u~ ~ _ LL~.`: