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HomeMy WebLinkAbout0346 iC_• Y4~.1 ~ 7~ 109. . rrPt?+r.ltr UW tt,..~.~r rr ~~I;N„ uK1GINAL STATE OF ilUN01S S~wlf~~lE 66•010658 Nuu~E~ n« +n~N~ i MECICAL CERTiFICATE OF DEATN ~tG~sr~~noM lf6~S~l~ID_ r.o o~sreitt wo Mvu~f~ '--f ~_T _---~--t-- pIACE OF QfA~N T USUAI i~K~uf?rCE /w?a~ a«~«w wnd u.~.~.~„~.o.. •~,e~.<~ t~ro.. . s?~tf s tou?,~r st~tt Il~o~B cou~rv • ~wwo~s Cook u c. ? INSIDE cwpad~ J~w:y ~ in C:Ip. Y~f/oqe. w l~cwpwoad io•~ c. ? INSIOf co~paor~ l;rw~li wd :w Cilp. Y:lloy~. a'n~apad~d 10.~ ° p8!'jC ~p2'@~r ? b - • ~ ~ d. OUTSIOE ~w~. i;~:n ~d M M ~ ~ ~ ~ d. Q OUTSI ta • /:~rb ad ~s ~N k a ~e ~ 1o.MA~p ~aw~ . . . . . . . . . . . . . . . . . . A ~c v l~ : ~ : To~mA:p wow1 . . . . . . . . . . . . . . . . . . . . . . . . . Reod D:iNK1 No Rood Dnli:cl No.................. 632'S 0 0 W1hAE OF HOSflTAL OR INST~TUTION o~ ~ N A~. RES~DENCE I?DDRKS b No. a RtD. o~d Ibd G~c~) ~ g ~N i~ o a A. 11 ~N u Aapf~l a~~sf~f~lw~. O~w SIrN~ ~ No. w t i ~ a+d w~ •c~ 3 1 0 0 0 f~ - ~N _ ~ q.' D~d d~cdee? i~sid~ ON A fAtM T YES ~P ^ l. NA6AE Of i~ 1 b. Iw~ 1 c. tl/? 1 ~ 0/1TE OF 1 M! 1 tl _ _ DEGd?SEO DEATH $LO t . S. SEx R/1CE 7. t~Al?RRIfD. NEYER hiARR1ED . DATf Of ~1RTH 1. ~ r''~' ~ WIpOW O ~IVOR EO (rp~c~l~1 w+~w rh ~wM ~t Fiemale i~lhite rriec~ 12 8 6 ~.7 ~0~. USUA1 OCCU?ATION Ob.KINDOFWS~NESSO~~NWISTRY 11. ~1RTHKACf (C:~~ o~d w ~0?.~9^ ~'r1 L~'«"a = Home t3e ~ ~ H evits ~ ~4. 1iAOTHfR'S FUII ~ ~ fATHER'S FUII MAIOEN NAhAE ~ N~~E Johann~ea Schnoo~ Joharna H ~ 1 S. Woi wcra~d ~w U. S. A..rd Face~) ~6. SOCIAI SECURITY t T. INFORnAANT O r~s, ~e, .~o.~) 16:.~.w. Nh+ M w-.c~) NUi~A6ER . SIGNATUR iE W ~ O82 'GV ~ .~?DDRESS ~di aQj~ c- 1~ TO . `T" ~ a1L Me~wrial H ital ' ' rc ~AE01V?l GUSE Of OEATH ~ - ~ ~ < rw~t DEwrM wAf GwfEO ~r.lEr« «+r o~. cwn. r•. r:•• ~~?1.1~1 w It1 l ~NT~vAtAM~~~Y- ' ` - 11N/EOIATE CAYSE r 10[iTii3~ i ~ Cancer of the .ung...(Pri.~nar9) . ~ N ........•---••i.... E Ca~drlio+r. i/ arN. IN h I~1 : , .AicA ~ b : . ~ M~ IM~AEOU?TE ~ • . ` < ~ » IC) ~ u?usE A~. ~e?Mw = ~ - ~ ~M UNDERlY1N6 . ua~ 4s~. ~ ~ i N w w A ~ ~ , tYEN IN ~At1 IIM. - - - - - ~ ~ 1~~. Mt~ M M'~~TNM. M ~rt ~~iw ~www~ ~r ~~rr~---- - t ~ ru p No ~ O { ~ NOTE: H~w i~ jwy .ra ihr~lo~/ i~ Na~ JM1i~. 11» CM~ ~1 M ~NfM~. ~ 'll. 1 Aniil c~d1r MiM 1 oM~1 M?~L~Ls~wd 1ro~ . N . b ~ , H . M~f 1 iwt ~w M~qMd aiM { ~ M - ~ wd ~A a ,~M~a. r» cw~.~ ~d iM ~ wM/ iw~. ! ~ ~ ~ c.k .~u.wn t~ v' ' sw~.a Februa?9. e. lp~ . a.. ~ 5;9~.ir..?. . . - - - Wil2i:~i ` . . . . . . . . ~ ' ~ E• 1ti e~ ' H' ' F Il o s _ : . . .M~o~.. PZ 8-6~~' . ~ ~ .z345n. iteatarn. Avs.... Par.k. . ciac~a~.. . . ~-c~~T~orr a~... . zs. FuNE~ a~cr wi ~ tt. asros~raN: - ~ , . ~ Rr . . . .K.~ . ~E . . . . . . . . . . . . . . . . . . . . . . . . . . . s~6w?ru~ ~ . /.~f!t.!!'TJi~ - ~'oo~t'- , /L L iw~s ~f ~ Ess . ~ .4!r . . . . . ~ ~ .,~.~.Z. . ~ toc.~t~a+ ~ ? ~ M ~ ~ , iE• " ? ~ ~ - - } ~ _ - - ~ - ~ ~ - ~ ~ r-. , - ~ ~ NEREBY CERTIFY THAT the foregoin~ ir o hwe ~nd comect copy oj ± ~ rhe record as made fion? the origir~a! cesh~catt for d~e son mm~td ~ r-=_ -~f ' t' ~ -henin and tJwt thir cerd'fuate was esta6lished and ~d witJ~ the - ~ t~epartment of t~?~biic H~a1eH in aceordmict wi j tke statutes ojlllinois. ~`s~ ~ ~ . ~ SPRIIiKiF1ELD ; ~ ~ ' i ~ ~i~ARrCH 6, 1979 - ~ ~ I ~ - ~ THIE 13 NOT A VALiD CER'TiF1ED OOrY wITHOUT THE EMBOSSED SEAL AND SIGNATUR~ OF THE STATE REOt$TRAR ~ '~;C3o~~'ae`34.5 ~