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HomeMy WebLinkAbout0344 t ' 264~94 ~ ~ ~ 79 109 ' 1b~32 ~ aiIASE OF ~t-LIf~0~6 i1W:~ . ~ p~~iRllT NO. ~ ,REGiS7fRE0 CORONER'S CERTIFICATE OF DEATH : t~:;r~~BER S~ ~yT S~( DATE OF OEATH ar• DECfASEQ-NAME ruur wioou , Nans fit~ffers s"'al.e 3. Se t. l~ 1 1 RACE wr.~~c ~:[~eo. ~uiw+ ~~+orw~+. AGE-usr • UNDER 1 YEAR • UNDER 1 DAY OATE Of BIRTM aotiM ar. nw PIACE OF DE/?TH ~~r ~TC. ~Sr[G~~~ ~14TNOA7 {~rai.l ~,pp . Owt~i : ~s ; ~ p . TT ~ Zg~r) 7a ~:!lryl{ -.rhite so. 8~ :se. ~ ;s~. • a.ov. C.IV, TONH. 1N'~. OR ~OwD D+STR~Ci NWM~IR 'tNLOF f1TY ; NOShTK OR OT~U 1NSTITUTION-N/lM[ (N NOT W UTK~. WV~ ST~EtT AMO ~MM4W) . {rt5/HOI . . . ,b. ^ni N~i ~3~ts ves :~a. St. •Ta~~~s Hnsni_t~l ~ - BeRTTRPIACE a~wTt w toaav+ CITIZEN OF WH/1T COUNTRY W1~R~ D a ORC Oa~EC~n N~E OF SURVIVING SPOUSE u.wov+?uwc~~w~~a S. •^:...-.,~n~~ 9. Tj~ 1 1la'.t• ..rP ',il. ~ _ 50'Cinl SECUit17 NUMBER USUA OCCUPATION ; K~ND OF 9USINESS OR ~NWSTRV ;U.S. W~?R VETERAN.~N~?R OR' DATES Of SE0.VICE r~2eti red ~ ,IrES/H01 ~ ~-,'n ~n~~~l I i~~iutcher t~. n ~3•a~ znP~4 ~ ~a~ *to ;~3a - R~S1OfNCE STwTE ; COUr.iY ' UTr. towr~ ivrr. O~ ~WD O~trnKr wp. ~M+DEC~TY i STIFET I~?~D MlWE~ . ~ {YES/NW ; ~'•f1^~r ~1~."7+~' ~'I1To e1; • 14d.V~'S '14 . ~Zn (1•3~{._~~1fl/j •r ~ 1 a~. T l l:.-. n 1 ~ ' 14D. i~RSi M~DOIE LAST tATNER-NAME ~~~T ~w~E twst • MOTMER-AM41DfN NAME ~S ,Tn{•nnn Ct'r1r~'I+r+C ~ . . R~rtha r~17(~i' ;~NFOi.MANT'S SiGNATURE , R IATIGNSHIP ~ MAI~ING -ADDRESS t~T~T a('~ o. an w rawN, srwr~, z~r; ~~P : ~ ~ ' •7 M Gr.qsf,.. ~ • V 4~4.~C6`~ ~ ~ s ~ ; o. ~ ~\l+?Z Cv~~v.?•o~ , -`~~L ~ n ' ATM WAS CAUSED 8Y: 1[a1Et Owr ONE CwuSE t[R urN ~dl 1.). le). kll ~rr~oa~M?n 1NT[KY 18 nrwc[.. a+ur ~ro awrM PART 1_ ~w~to+wTC twust ~l ~ t ST.IUCIE C UNTY FLA. 1i ca~ a,1 tA f: ro m,,~. i RAS ~ A OVE TO. OR AS A CONSEQU[NC[ O~. CLERR C{"". UI V~~ ` `~,f ~s AN~. RECORD vER~F EO ~.~,.E S,SE To ~rterio~rl~r~tir Heart nisease ~~•+~ED~ATE CA~~E "o) p~;~ TO. OR AS A CONSEWE~4[ G. /~T A ~u ; sr~;,r~ T.+c u~o[R- ~ 01?1 ~ ~ L6 M,'~~ i I~~NG CAUSE LAST. . ~ ~ ~Cy . ` _ _ i PART 11. OT?icR S~GN~FiCANT CONDITIONS: ewatar.s ecwe¦,~..~..e ro u.r» wi ..or u~..io ro u~u s~ey ~N IiUi 1 N: AU7OPSY • N [S. +n~ ..v.. ,z c~ 1YE5/NO) ' s•a•w M Mf~~YM~MG VWd ~ : 7 Ot~.~ ~ 190. ~ 19b. i ~ .;~,;•r <<:: ^(_IMW~1~7[. ' JATE OF (NIURY~~~TN~ DAV. YEAA} ?~OUR~ • MOW IN}URY OCCUftRED ~f~T~~~7W~a~N!{A~M(Ni~IJwr..r~ ~ ~~..'Eleiwr.[o~io(C~~r1 : 1 rut iqr ~ :,a. ~ 20n. : 20c. M.' 20d. T~_ tN!URY /?T WOAK PLACE OF INIURY ~T ~Mt r~~M STqEET • LOCATiO\ (GTr, V~L OR TOWN: Ol TM~?- OR ~O. QST ~q.; COWTr; STwTE~ ~ .,p: • I~CTJIIr. O~RCt 6bKN'.f.. [iC ~SOtUtr~ ~ ^i~~. : ?Of. : ~Or7. } g ~~~.~7iSY SIIAT iN MV 0~~4~JN, BASED U~'ON MV ~NVfST~GAT~.O~+ ' TME AECEDEN WAS PRONWNCE~ D ~ AT t ~ n'.~' a'a T~~E ~.QU11~T~ON. TWS DfATN OCCUQitED O`i 7HE DATE, ~~TM wr ~CMI ; _ Ai t~~t vI~CE A*.U OuE TO iME CwUSF(S) STATED. ArvD THAT • 2jb 1~~, 1Q71 ' 21~• 7•~~ ? Pµ• LJnO\ER'S SiG`ATURE ; D/1TE SIGNED ixw~+TH. o~r. rtwai ~ ~ i - ~*1.a1`i ~ ~ ` 1~ ; 22b. • ~~~~.t~Ncf. ~,~'i~ S:C.IAA.'~ i.NATURE : OATE SIGNED iMw.TN, owv. rV~i ~ - ` 9/S7/ ~ : ~ ~ ~ 23b. ~ :;i ~inl. ~hi~~A ' :CEMETERY OR CREMA70RY-N/1MF ; LOCATIONt urr ai Toww STATE ; A N. • + Ri~1JVAL ~x~ar~~ ~ ' / 7 ~ :t.t.~..n•..n~'l !lr~ '21b. T~n»1 ^rs vs~i '24C '~'12'~~r *~~»Pe~} T1l inn; SI'24d ~ ~ 1 ~ P`Tt'11" 7 F UNERAL 1-10ME NMAE STR[(T ANO HUM~[R pl t. i. O. GTY OR TOWM ~ STATE Z~~ ~ zsa. r.,; r ~~„1 ~ n,,. ~n ,.rP~t•.,no~i ~r P~rk rnre~~ T1 ;,,nig ~n~~~b fUtv[RAL DIRECTOR'S Siw'VATUR,E ` .fUNQK O~~lKT04'S IlllMpS UCENSE ?M!M{ER ~ 7 ~ 7 'C5 ~ ~c ~c-~' ~ ~-/Y`-~ : YSt.!{~~'! ~ ~ WCI~I REGI~S-R~A 5 SjGvATU~tE • , DATE REC'D. BY LOCAI REGISTRAR o-• , ~ ~ . ~ i'`'~ ~ - - - ~ z6b. 9-16-71 . VS :J:-(1716e~ l S VARTMENT Oi PUBUC N~iiH - eua[wu Gi STAT~STICS (BASED ON I~N V. S. STAI~DARD CENTIi1CATf1 i ~ ~ _ Y . . . - - . ~ - . / . ~ I HerebX~,~f.lp '~~f ~~t the foregoing is a true and correct copy of ~ the .d ~ ;,the decedent in item No. I anc~ that this ~ reco_~ ~ ~~~?~'~~,~d and filed in my office in accordance with ~ the.~~ ot~~`'Illinois Statutes relating to the registration ~ of t,,~ ~ ~is~d stillbirths . . . l,, - ~ ~ ~ ` . ~ ; ~j„w ~ gR DATB'~'~! : ~ - • o ~c • , S IQ~1ED : - ~ ~ ~ ~ ~ ' ~ , , . ~ - .,,t O\~ `~t~ - AT : Ctiic~s~,~~~~~ 11 TITLE : T.nreT uFr_Y~Ti~A~i--- " BO~K ~~9 ~AGE S~O U Q ~ $~:Y3U5 343