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~ -OHIO DEPARTMENT JF HEALTH
~a Rq. No. DIVISION OF VITAL STATISTICS Flk No.
• Primar, ReR. Uiu. Nu. C ~ CERTIFICATE OF DEATH Res'urat a No.
.c: q '
DECEASED-NAME linl .NrJJ/r Lur SEX DATE OF DEATH t.Nertb, D+>r, Ya+av
O
a i. mar ion William ~ NNSON
male ma 19 19??
~ ^ RACE I~bift, rrjre, ..t.irrw AGE- Ltr UNDEt 1 TEAR UNOEt 1 OAT GATE OE RItTN r.Nertb, Or/, COUNTY OF DEATH
~ ~ irJtrr, flr. rSpri//J brtbJr f)trrtJ )'trr/
.-1 - , .rq . ir. par ke
White s.. 6 s. Sr. ma 21 1910
~ - ~1 ~~T~OE, Ot IOCAT1pN 01 DEATH INSIDE CITY lIMI1S MOS?ITAI OR OTME! INS)IiUEION-NAME iIJ r°f rr Wbtr, ju r Ifrtt! rwI rrabtr/
l1 IS?tti/) ~q or NI
t'
~ v ~ ``1 ~ es Wa me os ital
v ~Q' • J '?II/ ret it I/S.A., rrwr CIt11EN Of WHAT COUNttT MAtt1E0, NEVER IAARbEO, SURTIVING SfOUSt t/f rrlr. jnr wrrdrr wwr/
WIDOWED, OlvotCEO rS?tri///
~ . ~ i ~ ~ ~ ~ o Eo mar i Ti. i lis H isser
G' ~ ~ ~ NUMBER WAS DECEASED EVER IN U. S. AIMED fOlCES9
_ . , ,_sti: I)'tl, re, er rrlrorrl
w i„~ b ; - Jb (tJ )ea, pw deers of rerutrl
1 _ _
ti.
O e 3; ;;L -i~{ N /Girr I+d of ror4 Jo.r Jrrirj pert eJ [INO Of WSINESS OR INDUSTRY
f ~ to ' r i/ r(tirtJ/
~ _ T
s. a " t Doctor
V ~ - jQ rSEATE COUNTY (IiT, YIIIAGE Ot LOCATION 'NSIDE GItT UMIES STtEET AND NuWEt
GU /a 1 , ~ D • ISpftil) )p M NJ
lab u< _ las ter. Q fj
U ~ _.-NAME Emt .NiJJ/t Ltr MOIMEt-AtwIDEN NAME 1 inr .\6JJit Lrt
~ ~I INFORMANT-NAME MAfuNG wpOtEiS tSnrtt er R.I.D. ro., ut, e. rillrjr, urrr. arp/
# C r-1 OD
~ •~'"1 r~' fARf I. DEATH WAS CAUSED ~V: :FN?Ef ONl7 ONE CAUSE IEt 11NE fOR /el, Ibl, AND f[!1 At?tO;IMATE INTEtVAI
FCCC-•+. ,t EtwEEN N f ANO DEAT
f:
G ~ IIMMEOIATE CAUfE IO1 ~ Q~
~i ~ Cer/itiowt, i/ uT, OUE t0. Ot AS A CONSEQUENCE Of
^3 rbicb sere ritr to , Ibl
C iw~rJiste rent L1,
urtirj fbt rwltr• OUE TO. Ot AS A CONSEQUENCE Of
l,irs rent inf
C.. (r
C'^. MRT 11. OTHER SIGNIfIGANT CONDITIONS t orJ.ti..r< rorlnbrti.j Io Jfrlh brt rot rr/rt(d fo rwru si/yw it prrt 1 /r1 AUTOIST If TES r t?e h.Jrrjr aorr+Jn6
e
rJ t) t1 I/ r0 rr JrtrrwrMlrj lJY<t e/ JIrlb
O A - Ive tvb
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U
A CI NT
C OE SUICIDE, kOMIUDE, DATE Of INtUtr HOUR MOW INIURT OCCUttEO tErttr rrtrrt rgrry rw prrt J or prrt Jr. r.tw IM)
I~ C1 ~ Ot UNDEIERMINfO ISprril/I r.\lorrb. Dr,, )'rrrl
~ l' 70n JO<. JOd.
~ INJURY AT WORK RACE Of IN1UtT ~t bowl, f.r<w, <dnl, Lr<IUI•. LOCATION /Shtrf or K.i.U. ro., riq er a/l.rjr. Itrtr. tr?/
~ p+ tSprn/) )tt or ro/ nl/itr blJj., rrr, rSpr<r/,/
. a JOe ]01 J
-r-i~ CEfTIf ICAT10N- ,\lurfh 1)r, )~rrr 1lorrb Orl ) rr. 1 ANO LAST SAW MIMl A!! 1 010/DID NOT OEATM QCCURRED .1r rhr p/rrt, e1
~ ?MT SICIAN
~ ~ AtITE ON VIEW THE tODT IMOUt! rbr Jrrt. rrJ, q
~ ~ 1 ATTENDED THE TO + Nvrtb Dr, )'tr? AfiEt OEATM.
`J Jlo DECEASED ftOM ~ - ~7 - 7~ Jlb .J' - ~ 1 - 77 , 71r / lrerlrJjt, drt f.
S - 9 - /977 JIJ. Jt•10 : 15~mtbr <rrrrtt/ tatr/.
t L, ~ 1 CEtiIFICATION-.CORONEt Or thr brlir eJ for r+rwiurrer Hurr <.t Jr.rrb Tbr drrrdtr! rrr prororrrrJ Jtrd
' ~ ~ of rbr bod, rwJ• or for iwtnrrjrtior, it w1 opuior, Jr.rtb .\lortb Dr/ Yw• Norr
~ ~ Vr<rrrrd or for dmr rrd Jrr to lbt rrrtr/t/ Ilrtrd.
y 7Jo.
C~ M. JJb ~
'v' CERTIfIEt-NAME tt,pr err purr/ SIG TORE
Ya r„• ~ tjrrt or tillr DALE SIGNED
J)e ZE ~ Jib n< -7~
r' MAILING ADDRESS-{EEiIitER StYEEf Ot t f D NO ITT VItEAGE iATE
v I to
y, 1 ne ~ ~ ~$e3j
' 'C> WRIAI, CtEMAT10N DATE NAME Of CEMETEtY OR CREMATOtT LOCATION I( u1, ullrjr, or +orrll/ fSlrrN
ti -Oi ,Sprral'1 1977
e c v, J' Ja J.< Greenvi J•. Ohio
L. rJ C7 NAME Of EMBALMER IIIC NO 1 fUNEtA~ G fE ! S SIGNAT Ii1C NO
~ ~ .
-L= y Js. Gar _ Js l cc-1• ~f ~ .~1 Z
1 i. i~ fUNERAI fIRM AND ADDRESS
ISiREET NO 1 I ITT) ISTAIEI (Ilf)
" n ~ J7 Zechar u 3?_
HnmQ-----~~ 4
DATE tEC'D tt tEGISiRAt S SIGNA/UtE
x tOCal tEC,~ t\~~ DArE ?EtMlt ISSUED S~GNAIUfE Of /E! N ISSUING fERMIi GIST. NO.
JtJ " .7 ' ' v cL'(CL~ln~v 1 y ~D
71
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