HomeMy WebLinkAbout0819 ~~:3'~'69S ~ /
RETURN TO: DAVID B. OLSON, ESQ. .~•j-; c.r;pF:~rp
5403 Aloha Place
Holiday, FL 33590
4:3'7695
'79 t:;',~~ 19 Ai~ 1 i: 57 ~
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N~„~ri,,,,.. U~ l 6 U S
CERTIFICATE OF 1)EATH s~`~' F~' ~'1O.
~r~~rE: uK r1~?nr? s~O~
p ~ a 1?~ tv0. Cuslodi~n'i No.
~NAM O (Flrsl) (M~ddie) (lasl) 2.OATE (Monlh) ( y) ~Year)
OECEASED OEATH
- Michael George McNichola Qctober lt 1978
J. P~AC O DEATH ~Counly) USVAI RESIDENCE .~~c.a~lcce,ncd~~ed.l msu~ui~on:~a~enc~ w~somn~ao
Fulton ~/V~/I s,,t. (}eorgia co~~~„ DeKalb ~ ~M
C~ly w Town 1~ Clty Llmils! Le~qth o/ StaY ~~jlyZ m s enq o s sy
? Vei ? No ~~~s p~~Ce) ? Vet ? No (in thls D~at~)
Atlanta Tow~' `
Name Ot Nosp_ O? inltllutlOn lEn9tA O~ Stay Slreel Atld~Kf O~ R.F.O. and Box O. ~ D
St. Joseph~a Hoa ital Q~.~ng eek Road Z ~
5 SEx 6.Rl1Cf. l. 81RTHP~ACE.3-.~c ~~•~.,;nco.,~:~rl Gliren0l wAat IS. IS RES~OENC[ N ~6• BURIA~ Date
touniryt FARM~ REMOVAL 10~~78
M CsuC. Ne~? YoTk C1~s N~Y• U.S.A. Ovas r~o CREMATIOIV
AT~n B~ . AG ~~n yesr 1 unde~ year 1 under 2 N~s. Name o Cen.etery Locst nn (C y or own ~ oun y a e
lail ~Irthday) MontAS OaYS Hours Mins.
(ireenfi ld emetery sau County, Nerr York ~
i-1-1903 T5
' t MARAIEO M VER MARRIE If mankd w W~dowed m separafed. 17. R A cense um er
~'N~vOWED I~~IVORCEO 9~re name oi apousl. C~
?SEPARATED Ethel Smithmen McN1~ 018
1: USUAL OCCVPATION (Give kind of work K1nd ot Businesi or Industry le. / ~
,r du~lnq moil of wo~kinq ~ile, ~~~~«a~ H. M. Patters m& 3on S ri Hill
Insurance ~ p ~
L wn5 DECEASED EVER IN V.S. ARMED FORCES~ Sodal Secur:ly No. 19. FUNERAL HOME AOORE55
~vee,}~oO, O~ unknown) (11 yeSBive wir or dalef o~ servit!) O~~_~O_~~^~ P 8 • f f g
~ 1C~20 S rin Street N.W Atlanta Geor ia
FATNER'S NAME 20. INFORMANT RNallonsh~p
Stephen Mcllichols Y~.. Michele Rubin Daughter
~.~~~THER'S MAtOEN NAME ~ I_ INFORMAN7'S ADDRESS
Pl o R~c ord 21 S r~~reek Road~ Decatur, Georgia 3~33
~ . 2. C/~USE UF pEI1TH ~ intlr on~y ont CiutC ptr hne oT f(~~,(b), and~C). L SE~RITV~~ f--~ tnierval~eTween ~o ljo ~ ~ Tn Tfiif ~pa ~
• o~ut and deatn 1-
~'ART 1. OEATN WAS CAUSEO BV:
i 1MMEOtATE CAUSE (a) r 2. 3. /
; 5q 3 I ~ ~ ~ ~ - ~u~~ J
nc1~!ions It any, UUE TO (b) 5_ 6.
i h qavt rlse to
~,ve cauu la?.
F ~ :~+t~:,q ttie u~Aer-
~ .~n3 cause Iast. _ OUE TO c
~ :'i~[~T 11_ Ofner s~qnf/icant contlrt~ons contrlbut~ng to deatA but not rNated to the taminal distase tontlitlon 9'ven In Part 1(a). 23. AUTOPS~I'
~ V es No
f ; i~ OvE i~AT10N f RFORMEO- 24a. DATE OF 2 D. 1 W
€ Cnmoiete Ilems 24~a and 24-A UPERA710N
~ ^ - qree o. e
~ t h eDy certllY that 1 atlended the deteased~from
to 19 Z. that I last sa the deceased
ress a e ~qn
~ nn _~~i~ , 19 . and Ihat
~_^at h occwred at m. /rom the causes and Ihe date state0 above.
~ ('t)Rl)Nfilt MF.III(:AL FiXAMIhER - Pllf S~CIAN
3 ~ FACCIUENT ~~dCP. O~ Il1~U~y ~P.9. If1 O~ about In~ury Occurred (C~ty or lown) (Gounty) (State) l~me (Monih) (Uay) (Ve~~) (HOUr
SUICIDE nh~~me, ~a~m, facto~y, sireet ?wh~te at work ol
r<OMICIOE ~lo/lice bldg., etc.) ?NOt wMle at work Injury
~ - .
How did In~wy Occu?~
~
~ f~A TE RECEIVED Coroner's S~gnatwe Address Date S~gned
~ C0~70NER
~ ? t~A ?E RECE~VfU 30. REGISTRAR'S SIGNATUfiE Date S~9~ad
~ ~ ~ LOCA~_ R( GISf RA ~AL1~SN COUNTY HEALTH DEPARTMENT QCT 1 7 197e
~ ~---Q~I~._i_l97 ~!J~f/~ 99 suqer s~.. S. ~..Atlanta._GaQi~~Q~
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~ orm 3903 IRev. 6761 `
~ ~ ~ - - _ . _
~ ~ 'I~f~is ;s rc~ certitiv Chat Lhi~ i~ true ailci c.orrect co~~v - ~r
e; ~ r~~e ccrt i t-ic~iC~ f i 1~~~i ~.-i t_J~ t:tle V~ C:~1 I;c~rnrcl~ Scrvice , G~r~~~-y~ i.~
~ I)~~:~.~rtt~~~il~ ~1- itt;~;~:in i:~~sc~urces. '~his cc~r~i I ic~~l capy..ZS~•~~ssu~~ci
> c:nt,~~r ti~e ,~>>t.',ori~ Ci~;~}~~ter $5-17, `.'ital Keco~~' _C~de•:o~ .
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