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HomeMy WebLinkAbout0764 MARYIAfVD STATE DEPkRTMENT OF HEALTH r Division of STATISTIUI RESEAR~H ANO RECOR~S, 301 W. PRESION STRfET, 6AlTIMORE, h1ARYlAND 21201 , 43'~662 ~ERTIFICAtE 0~ DEATH ~'7 ~T ~ . J y 1 PlA(E OF OEAiH 2 USUAI RESl~ENCE ~~.`.e:e aaud '+~~d. d~ntit~•~t.on Rts~at,-~ca Galort cr ~t^~ . o«%?~TY o STAif b(OU\tt•_ 7~~ ~ ~ ~i7'I~ f .=Jfll%~ StdhY~~UO - f r ~ ~ 0(1TY OR TC:S4 4t ou's.de tot~q t 1 T:ts likGtM 0~ SS :R lo ~ c U1l' OQ y~1V if ounale co~r t~+m.n, ro~e iu t oro c,,:e neo;~st rownJ • ~ .7 M/~ ~Sd ~~i ' ~ffS~ Mi t ~ ~ ti ~v LL'!!!- i _ 'l-~-~.~' _?/I ~ d h~ME OF ~~+'i Oit Tt'.UiiOii (11 e nosp.ru~ 9.r~ wai ooseu) ~ I d STRtiI W3ic[S ~ e~ ~Atc ~ ~ y~ ~ ry O~aFil251?~ - V ' 3' ° 1~ !~1" ' j~ ~.li.c 1[S !i0 I1N j-~ ~ 3 N~5!E OF Fnr • w,-•• ~ ~ ~ CATE nm Jor Y~c~ • ~ DECEASEO I ~ -y : } ~'~x or prm!; r~~ J°~i / • / G~ / J GFATN c= .~-~"a~ ~ iY ` ; v S SF7I 6. (O102 IU(E 7. AAAtR~ED NfVfR M~IRRIEJ ~ t DATf BIiT~i /C"C~ 4. AGE tn pe~vs !i:`.~E~1! YEAP ;i ~~.~iR?~ / i /~y .tv.ooy) Atu~~hs D~p Mo:ns Mm. ' . ~'p ~c ~.'%f~ / - w1D0'~if0 ? D~vORCEG ? / lt' ~n, rn . ~ ,iw~S;1.1~~CU?aT10M'Crvek;ndotwaadorn IOb.K:ti00~8USIAESSOt I1.B:~tINPiACEj(owuydS~a~e.a egnia:m~ ~ ~t O;~:ir:OFYltuli tl~ : r,~+, d, r;; qas~ oi w~~ir~y L~s. trm J ~e;~;zd}~ i~Q;i~iRY_ , (O.iNT i~Y ~ 's •Y 1 ~ -t- " ~•7'/~'~~< <v E=~7j~r'c: •r ~ ~ rc- : c<<-c l . -.~,n r, 13 f,1in;R S~l71.Mi , ~ N- t4~Tit~jt3 dAA:J:. , ~ ~j~; ~-y~ / ~ , ~.<<-~/'~-' % ~~y'~ •7'~iC' L '1~ <<. o Y'aS ~c.i~SED EVit U.S :3tki0 FOA(ES? 16. SOCW SECUtIn NO 1) INf i • s~ i i~~. ~ iYES. b. 5f ~f:[~OVlnj It yes g.r~e •-n7~r u ~'ciES ot sen:u / ~ J~`~ l~L~ . ` n ~ / ~ /S / ~j ~'C ~ ' i~ 7 .,~~r_:G ~ ll CAUSE OF DfATH ,Fnrrr atiy one cuuse pa : ia (o~ (b~ and (cj) ^ e~.~~~ / ~ ' ~ti'.E,'.'t., ~iSitiiEN PIIRT i. DEA1M WAS (AUSiD 8r: + r~. , G\SfI a.tJ u;A7ri . t6t~lEOGiE (AUSf (a; 1 QtIE i0 { `Coe~11i} {an! w~+ch gare j ~p} ~ ~ ~.bi ~ ~ ' . • i , ~ s , ~ q' ~ ~ 1 ?y y~ ~ R P ' a?~~ w,jLi~~ ~ri bS ~ • ' ~f~ - . ~ ~ a~ ~a~s~ (o) ~ + y r coux • i0 i 1~ ; . . J ; ; ~ _ txt.° ~ <<~ ~ : _e = ~ , ~ "•v.,~~~~y~!r#-` " a (pND1Ii0.~1 CC\1Q.BCi~HG i0 GfATN BUT A0~ RiI~JEJ i0 it!f TFitR~:~:id G:4~S:'tGi9iifOti WYiK iA TA3i 1(0} ,~:~f x i~' ~~.~~1: . ^~."_.1-.'•ir.s=~.~~'+i`-~ "ci~ hJ ~ ?~'Ktr ' Yi ? 2Go D[SCR:dE M;M J~.~tY GCCUZRiD ~En;tr'ra:~rc oi ~:a,r~ n Port 1 x?~rt of ~:am Ic; ~ i S~: ti. lqiff RfATM , , . . f . ~ ~1'. [~17tER) + ~ . i. • ~ v ' ' Doy. Year .Da iti.:.Rr 0(iCRIiD 2Je. PIME Ci t!i;JkY ~M~c. tam. .~f iCay or tow~) ~:.,,:,tY~ ~~rataj 'yti~ , f, : . ~ f ' :p, ~ > 1Y.-.:4 Not'~hT,te locb.y,s'rrit,offKebt~,ex) ~ij'• ~ t .L, ' ! . ~ ; 19 c~ w;.-r ? ct wo~k ? 1 _ ~~t;t~ ~ „~fCi ~I (Sitii IiGSMitOI~ a tended the deceased from , 1~~,_ f , to ~ , 19 - ; !~ct ~_:e! Icst i r,: ~,~.aceosed clivz on ~ - 19~., and that de,:th otcurred at_'~t~l,fro^~ cousrs c.~~ on :;:a ~cte s?e:~~ c5o•:c. LL. • . • :.a ~ . , a~~~ s:,.,_~ ~ ~'~'~i / ~ /I ~ .,,T..ou~ ~ ~~~o :~u~ , _ ~ '-7'~ -II ~ : I~ .i~, N D. Dr.1S ~ D'~:iI~2 ? PntS ? ' i~ ~ ~ - ?i~•::,:.i.S ~ , ~ Yia l.:~RfSi / ~ - ' J1~'~ :1 ~i~.~ _ _~l . " ~ ~ ~I . ~ t t ~ . ~ ' J =t . ~ - - f -i ii~ o 2io GRIi ;r.•2/EGi ' _h• M< Gi Cf:7: 0~2 G: Si„aY . ~;3 ~ \ . ^ ~ % . . rJ.a~,,:r~~.;~~. ~ ~„f - L % i_,, - j!%~. _ ~.l~~~~-- ' . r , - 1 ~ ZL ~ •~.r:(w~ ~ ~ ~ . .L`3.i:~ESS , " ( > n.i~v ~Y ~i:,:)in:i~T-;;1~.Sii.Ri ) , / a - t ~`i` . i l j ~ ' ~ ~ - -'i-. ' t"~~~ ~i 'l . ~ t _ 'r_ ' " _ _ - _ - _..r~='~ - ' _ . _~"_'c_ . ~ . Y ~ ~ 1 i ! i l ~ ~ € s , s € - . • i\ & t ~ 43'76b2 ~ ~ 'iJ ~ ~ I~ ~;:`~1 53 ~ ~ y - . . - ~ _ ~ ~ r. ~ f ~ _ Y ~ ~ ~ ~ ' 3v;~ c~?5 ~ 1 ~ s~ ~ ~ ~