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i ~ OHIO DEPARTMENT OF HEALTH
R`~' °i`' r'O' •i• DIVISION OF VITAL STATISTICS SIAte file No.
E'rimary ReE. Diu. 1J:` ' RrRi.t.Ar'R No. ~L' ~ n
CERTIFICATE OF DEATH
DECEASED-NAME fiat .MiddJr Ltt SEX !DATE OF DEATH (.Tlortb, DJ,, Yr
T. 1W~''t E F. dC GI:ILa:,Y at31e ~ hs3rch ~l ? -~"'F
RACE ~"Fitt, +rE.o, rArrritr+ AGE- Lett UNDEt 1 ttEwR uNDFt T OAY DATE OF a1atH r ~lorrb, DJ?. COUNTY OF DEATH
f,rdlJr, rtt. rS1+r, r/)i bi•tbdr> ( eJn1 .Not. Dr,r Horn .Mir. )~rJr1 ~
t 'ylt•:itre so 7~ Sb sc. NOV • 12 . 1900 la Cl~_j 3t:U:
CITtt, vlltAGE, OM IOCAT~ON OF DFATR INSIDE CITT ItMITS NOSiIMI 7R OTHER wST:TUhON-!NAME t!J rN tY eYbrr. Ent urrrt Jrd Nrwtstrl
IS?efi/~ for rol
7s. ~r'ie!:E'13T2!: 7c. lt'S 7s ~VeT~2t;' ~::5~?lt'r~iS .7T ~Et%•.~.~ 3: is
STATE OF allT?, +1' •or i+C'S.A.. wJwr CITIZEN Of wnAt COUNTRtf rrARe+f O. NEVER frARRIEO. SURVIVING S?pt,if rJJ Ydt. sut r+J/drr r.rri
torrrr~, w10OwED. DIVORCED rSOrnl+!
a. Ohio 9 U.S.A. To Mzrried T,. Irma Kavana h
SCCIAI SECURITr NUwiER ww1 DECEASED EvFR IN U. S. ~?eeEO FOR.ES' ,
t )'r;, +O, I/ Y+~rBY ri •/J K!, Et ur '~Ortf Of frn7R•
USUA; RESIDENCE ~7N. 272-U1-6427 ,7b ?I0 '
nnERE DECEwiEO ;1t'JAt CKCU?ATION Il.r:? i+rd of Y..rk dowr Jr•IrE ~ot1 0l KIND Of aUSINESS OR INDUSTt7
, vfD If DFAid y,,.1/rj :Irr, nu d nturJl
~c,uR"ED Ilb General Motors (Fisher Body)
~~st~,~..T cam, GIVE Su ervisor -
,=5 DENCE lEFORE ~~5, ~F~~---Tw'f 'COt.NTT ATT, vtllAGE O¦ l'KAT:ON ~NS~DE Cltr Uf?rTSlSiffET A•+D ~Ut•REi
Ohio i 7lb Cu aho 3 -a Cleveland ~ •.e Yes ~ I.. 17513 East Park Dr.
Fq:NfR-NAME JIIIt ai.id/r L.bf ,MOTHER-MAICiri KAME !Irr• .t1rJY/r L,U
„ Thomas Mc Ginle~ ~ Mary Kane _
Y INFJRMANT-NAME r MAILING ADDRESS r?r. rrr or R.l.U. rz, .it? 01 u1JJZr, rl..a. z+p1
Z 1I
'sirs. Irma Mc Ginley 17513 East Park Dr., Cleve.? Ohio 44119
Z MR7 DEATH WA5 CAUSED ELY: fNTEt ONtr Ot:E CAUSE IER lwE fOR ref, .a. AHD Iu7 Ai°'~"""!r` '^rf°".
aETwEE!N v.fT A~.u Ctl
J
Z :a t _
IMMEDIATE CAUSE -
DUE TO. Ot AS A CONSEQUENCE OF:
Corditiorf, i/ r+T, r _ ~
rrbicb Er•t rite Io (b)
iwrlydirtr uru trl,
tt..rirE !ht rwdtr• I OUE TO. OR AS A CONSEQUENCE UF: / _
E ~ hirE tJrre JJrt .r• ~
i l `
~i
~ ?ART 11. OTHER SIGNIFICANT CONDITIONS 1 v+Jirlort i•irh:brh+E to ,i rJlh rrt +ot rrlJltd to iJrtr p,rr ,r OJrr 1 'JJ AI,TOiS7 ~ !F 7ES Y r•r •lJ'Jt<' u,•lr
t i ft o1 r0il I+, Jrlrrw~rr,•( u_I r Jr_
4 - 190 ~IOD
_ wCUDENT, SUIGDE, nOMIUDE, DATE OF INiUR1 HOUR LOw INJURr OCCURRED ,E+trr +Jtrrt o1 Ir/rry Ir DJrt E or pJ•r d.::rr•t !K;
OR UNDETEtrwINED tSprr:fll / Tlo+ti=, DJi, Yr.rrl ~
_Do. lob :o:. 76e.
INICtr AT WOR( iIACE Or IN,Uf7 Tt Fort!. Irrw..nrrr ..:.~•I.I LOCATION .~r.rrt or K.I.D. +o.. my yr url..~r. n..rr.:.^I
rs~rnp Ir1 or rot ~ •.l,:u o:JE.. rrr. tSpruj)/
y 7e. ' :ol
~ CERT,F'.CATtON- .Tk.rth UJr Yrrrl .llorrh 7 ur ~ AND LAST SAVr_M=M:nER Di0/016 NOT I Lfrtn OCCt.aRtD ,r t%•r ?:J,r
FnrSICaAN ~AtIrE ON V;Ew inE aCDrl'fOURI :r•r 1J•r. :.r~. J
~ ) 1 ATTENDED THE iO .Tlowrh UJ? YrJr ' AfTEt OFATn. ~l ~ ~ ~ rni br t c r
Ry 27a CECEASfD fROM ~ 711. i 2a. ~ 210. ~ Ilr F M rhr t+wr•;r ,:_tr_
CEiTIFif_ATtON-CORONER (1r thr bJlrr of thr rrJw,l+Jrr•.•. ilow• of Jr.Ith Thr dradrrr YJt p..,ror+: td .:r..d _ .
of for rod? J+J, u. the I+I n:rsJrv.r, I• +t? oDl++or. Jr~r.~ ~ .~lowth UJ, 1rJ. Jfoir
ourrrt.l or for JJtr Jr.1 Jra :r. tb? ..~r+r•tl ,l..rr1.
Iio. - M. ~ 27b
rEtialfr.tN.us ._'.Dr or Dnru' S.~-'IA'URr~ Ur;rrr r.r n_rlr, - . GATE S:GNEJ
Tic.-.- art ~~o~ -.C ~j 1
]la _ _ _ 1
MATTING ADDRESS-{ERftfiER i2iT 04 a f D- nO. C!T7 OR V~IIAGE S~A:t :c
a ]le ~ - rte? c-, :.oGLa ..:..C~i:i. G~ i~ Z
_ WRIwt. CRErAT+ON,Cwt~pril 3 r.AerE OF Cc+:~E~r ~+EMATOn lO_AtION ~c nL :,:J.rEr, o. .orNryr ISt•tr•
~ fSpr,r/FJ
2sr -$uri$1 il•b. 1976 All Souls ..e Chardon Geauga Co,, Ohio
^F NAME JF-EMtAIMER .,.C NC 1 FUME DIRECTO ~S SI ATUtE/y e ~ 1tK_ r~O1
~n Eugene C. $rickman _3798-A I - f~/T,/7J 3:95
_ _ - FUNERAL iIRM AND ADDRESS tSTiEcT NO.1 tT(l • T :STATEI 'l'•'
'w ~ i, BP.ICKMAN SONS, INP.~ ?1°i~`0 Euc'_id Aye. _ Euclid Ohio 44117
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_ OATf.-tcCC at f'~.STFIt S SIGNAT~R1:^, ~ ~ ,1:ATG fFRMIT ISSyEO (SIGNATURE Of ?fRSCN ISSU'NG ?ERMIi JIST. NC
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