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HomeMy WebLinkAbout1752 442111 • /t[YANI NT ~CN11/KATt ~ n L t(.•t'ot+ARr REGISTRATION BTATt 01 ILLINOI• ~ I TA1 i ctltTlrtcATt DISTRICT NO. ~lp•O + w='n•~•~'++Yb REGISTERED CORONER'S CERTIFICATE OF DEATH NUMBER D EASLO--N I+u ooaE LNT SEX GATE Of D[ATM •/w+tN. wr. vw` T,=v N ~•r•f in - rItYAYINT INK I C1 D/.~ Z---•'/~~ •~.~~C• SN A AWrr/~11M ~ RACE stpo, ArtIIICAN WpMt. AGE--awfT • UNDER 1 YEAR• UNDER 1 DAY pAT f BIRT 1roNTK Mr,rtYt P Of DEATH ~owTT- s r,~wa O+nlvt ttt. tvaa• wtww r1 ETRSS r+o~aeoe( fa ~ ; Ypt. ; OArS NOt1~1 A•lTI. I,rs I nK rtONf t. I~ So. ~ Sb. : Sa 6. / -7 70. ~ p~- C=tr, tOw11 T OR twAO pf1R~T tANMQ • wyot aTr ; NOSNTK OA O1Ntt INSi~TU1 .r NOr Mt tITKR•itvl mEtT Ar.p NW(W :a sn+a ~b. ~Q ~ ~7r. :7e. SCUT ~nT ~-~o5~/TI~L~ Al~n BIRTHPLACE piw tM roatwt CITIZEN WHAT COON RY MARRIED NEVER MARRIED. NAME OF SURVIVIhtG SPOUSE yweotwut.trlrlttt ~ . couNun ` • WIOOWE6, DIVORC[Ots?tcurl e-----------•-•-- e. tides 9. Io. 11. /QvTff JC .CA/QS~~ IAL SECURI NUMBER VSUAL CUPATI ~ RInO Or OuslNEli Otl INOVSTRY ;~UNW AR VETERAN ~ WAR OR DATES OF SERVICE 12 02.3 - 0 9~ 130. M / ' 13b,/~/gNt•F /.T/6 ~ We. ' 13e. GNe~ RESIDE E srAtt ; wwtr • trT., itiW~t rw. a .o+r ptt•utT w • nsoccm • sTttttP ANO Ntwua w, p------------___.- Uo ~/v~/.S •1 ~d ~ ~lic~ ~C ~ ~ISd ~ '1~ .~/I''~~/~'~I~~~ E _ _ _ _ - - - H rlasT tr10oLt Hf N rulsT moat EAtT 1S. C 1 . INF TORE t REIATI IP ~ LING ftTIItET AIIO tt9~ tM IL r. o. OTr pl •Owt1, srwn, tN7 ; • 170.® ~r/"t`i/ . 17 4 ld. OEATFI WAS CAUSED BY: EtNiu oNLr ONE crt,st KR LMK roR 1.l. w1. ANO kIl N.' , o'er,,, I----------...___ PAR 1. rwtoutt tAUSt ~ k 2___________-.-- tot Q e - 011E TO. AfACONftOVtt(tOt i • ' wM wT GAVE tA=SE •t1/d (bl ~ ~ ~~G•J pwiE CCAUSE t STATING TN( UNOttI. Ovt TO. AS A (ONSttllJl•Kt pt. = icl PART il. OTHER SIGNIft T CONDITIONS: co••ar~ows <wTw.r*Y.c To a.TY WT YpT alwuo r0 CAUI[ (rYIN w r/u+ ~ •N UTDPSY ~ Yo•:~•~ ~~i~~~ ~ - - 190. ~ ~19b. , KC~Uvt SUK~Ot. ••O+•K=Ot. • DATE OF INJURYIYO••M owr- rw~ HOUR 1 HOW INJURY OCCURRED a.rTt. NAT.,.ta w:u•~Yt.+o•to J.Ar• O~ w•ant••~MO lstaurt ~ • , p~ 1M1 Y IT[Y It1 ~tlfiQ~'~/~ y/ QTiil? o r - 2ca.,~CC/O.~/YJ~ ~ L' /~7~'' : 20c./,'o3 r: M. ~ 2oe.AuTO--f'i`~RCC~~iF rRycK e o~~? Sim c- INJURY AT WORK :PLACE Of lN1URYw NOM[. uu.. s*eur ;LOCATION tGTr, ML Ot Townt; OR TW?. OR to. asT. t•O.; ~0u•rrr; RwtU I~tt NOT ~ tA(TORr, piKt MKpNIi= tTC- OMC~tr1 • . - - 20e. a ~ 20f. i ~'-~f--/L~~/vn~ I CERnrr TttAT IN My OMNION, MSEO UPON Yr INVESTiG•TU>"t : H C N AS PR OUNCEO ON AT ANOKMt THE INQUISITION, 1NIS OEATM txCIJA(EO ON TNf DATE, ' MONTN pwr rtAR ~ . 210 AT tME PLACE AND OU[ TO TttE CAUSEESI STATED, AND THAT - - - ~ 21b~~ 7/ ~ 21C 1~~ ~ M. CORONERS TU E _T ;GATE SIGNED wwTY, pAr, rwI 220.© ~~'S^~~'1•N ' ~ /V/ ' 22b. CORONER'S PHYSICIAN'S ATURE .DATE SIGNED IMO••iK Owr, rtAq i?... j BURIAL, C EMATION, :CEMETERY OR CREMATORY--NAME ;LOCATION uTr a TowN siwtc • ..a• z~Crcmation ~ York Cre:nator•~ s =•Lnhnrst Illinois ~ 1?--H-75 2<b. ~ 2ta f . ?te. i FUNERAL HOME NAM siRetT wNO Nuwa o~I t r. Tn t:trr a TOtrN srwit tv 2So. J. Su~rth Chapel 6754 1!o:-th::est Hi~h::ay Chicl,;oT Iltino;s E~OE31 { FUNERAL OIRECIORS SIC~lATURE rtll•gAL a(tcrws nuNas tKwst wMea - ` sb.® '~~ltcr P. Kezlor~ 63oh LOCAL RECtISTRAR'S SIGNATURE ~ OAT EC'0. BY IOCAI REGISTRAR•~•' M• E JOHN B. HRLL' I'!I.D. - ' ~ VR 202 (1l71 h _ Illinok pa Public Hsslth - OHiu Of VEtai Rt~cor l0ASt0 at 1 i STANOwaO Cotnrlu?Tq z F { ~ , - . • ~ - - r:', ~ t I~ It-LI~E'l1S• 1, c-1:~\L1:1' T. fCUSPER, )R-, C~una- ('Irrk o! the County of Co1T~, in the S'acr c_~ • f Gr~k. } " ~foresaitl, al~d Krr rr of the Rtror.ls an.l I'ilrs of s:II _ ~ p '.1 Ccsun:}-, du hcrthy txtlif}• th.It t:^. ~ aaach?=1 i. tn:r anti corrtc; coi.~ of ts: c•::o;::~I Rrcord oa tllr, all of winch aP~:.trs f rr,~t ~ ' - the r~-./~rds ~c:~ files iu rry tlffire. s ~C't"!-\FSi ~t'[fEREOF, I hrTt;llelttti~}to set m}. lur,/! : n:i F fnxr.l ihr ~.•,1 of il•_ C-r_.~.~ of Cas~S:, a~'rn}ffiee iIt the Ci.} of - I ' j t- ~ ~ ' 0 r ~>'~~R 210,^ _ 1 ~ , r . ^ ~!~i /I?~~i`L T 'S .j' Coltniy CICt~ • , k - '79 r ^442111 _ ~ .,r. 25 ~ 1~ • 5 ~ RECORD b RI=TI:^41 TO: ~ - ~ . cl . _ . sQ~K307 1752 { ~ ~r~ ~