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HomeMy WebLinkAbout0892 . , ~ ' , . . ,:.t~ ~ i DISTRICT OF COLUMBIA DEPARTMENT OF HUMAN RESOURCES 4~~ sc Rcad " r~~,cat~ " " CERTIFICA'I'E•OF DEA'I'H 7G ~2382 ' ~ iYt~~ FILS DATL F~u Na 1. MJl1f! O! D~CiAim ~~r.r A/~l/t~ J.s~t !a. u~7'8 lfoweA D.r Y~s. ~ fb. How et Drt~ ('lyp~ ar Pri~t) l ~ ):~C ~\~I 1' 1 ' ~ -~i DsATS -.3 ~ ~ ~o ~ O L~ L b'SIC 4 C~OWR OR RACE 3_ ~T~ver Aturinl, ~t~rr UA7'f! OF B1RTN 1. AtiS (Iw y~ n t ' vCido..a. D~vaeed: 9pec,ty - ls~ evtlW.r) o.r we~ M. as~ s~onld b~ ~.t~ I T E l.-v:c r, ~t i_ i E' •T ~PP~d' ' l YLACK OF DSATR IN 1~/~On. D.Ci. f. CSUAL REBID~NC6 (WAar l~ewrl 6eai. /j inditrtiw. twiitwu~ b~Iw~ ' IdANB OF HQ9PlTAL, NUR131N0 HOMS OR OTH6R 1NST1'CUTION 8TAT6 ~ S. wtAi~w) ul .oe ~ :~.rW.e~... .t» u.cet .tlnu~ ~I • aR yc./~M n]E • e. CI'CY e. ~IN81DE ~ ~iTa) va 'rv sborild b~ ~ ,1 C+ i' V~ C L G. ~ ,r r E ! ! ~ a . d. 9TRBIiT ADDR888 u! . +«u~) : ~d Ia p~- (~`J ~ GL /Q S l' H~ ~L GA , r i t7P~ ~~t 1 I?8UI1L OCCi1PAT10~I (IiN !i~ oJ oor# d~se IIb. H[ND OF BUBIN8B8 OR Il. BIRTHPLACS 1L Ci'[1ZB~I OF RHAT (70UM'AY_ twiy wNt rw~kwu~ saw ~ inr) - INDU~RY e~? /a+iA ~*~~1r) 5 e ' r , c ~T lk F~'IHSR'9NA6tS lib. N01718R'8 MAIDB~I NAatB 11- NAWB Ol? BIIR NO SPOl18B ~Gnrq7't a~5 ~A +nt LrorlSK ~ Ni? D 1V ~~c.D /4~7c~ ewsEt! fi. Sve~ is U. 8. I~. 80CIAL SIDCURITY NO. q~. 1NF'ORMANI' RaL 4TlON8H/P TO D6C~A36D llb. ADDRS38 8he~t ((Sty ~b , p~rsnaa~a! r«ee.T ,21 - _ O / 7HCc ,~o~C E . ZL'C~ i ~ EG otcSK/ - cfc~ 2- ~i c~-~ _-a~-f` fOOSd w~il ld. CaOi~ O! DLllIG (6wtn owhr ow~ t~ws tcr liw~ lor (A). ~nl ~ Iat~nd Bebrer QYR Y~~~~ PAR1' 1. DSIITH WAS CAU88n BY : • ~~~u = la/!lSD1AT8 CAUSE 1 Co.ditiowi. ~J Av. i . v~hirA N~s rw to DUB TO (b) ~ DD fttbtltlt t ~6o~r ~wu u~t- - iw~ tM w~srlral I ~ ~ y i ~ ~ nvs ro ~ ~ A~, ~ PJIRT II. O'1'HSR SI(il11FICANT OOPID1770~t8: contributias to ded6 but sW 1A. A[1'1'OPBY 7 ltb. II Xs. Wate $d~aP Oowb~ed R~fh~II ~ ~eMted W th~ tnmiml die~M eo~dilia~ pvs in part 1(~) YS8 O ia D~teemei~ Q~ure ot Dwtit ~K i.7 IF OPERAI'IO~i WAB PSRFOAI[ED f1~. DAT6 OF OPERATION fOb- CONDITION FOR WHICH OPSRATION r •lOlet~Ot1 O~ h Cl01SPI.ETS ITE!!8 70~ and fGb WAB PERFOR~[$D . - : of ih~ Dls- " ~u~~ !1•. 3peeitr it aoeideat, wicids, lwmi- l1b. xOI~R A~iD D.?TB OF INJGRY : btoot6, Day, Year lle. DESCRIBE HOVY INJURY OCCURRED ~ a~~~~ . (Bwed w~treva oJ Iprry iw P`se I or Par! !n . ~ !Id_ IN)DRY AT WORH: t1e. PLACE OF 1\JL'RY: (At Nowe, Purw, Ixtort~, 21L I.OCATI0~1 CI1'1 OOUNTY 8TA'fS (d~tiJy Yss or .Yo) &rert or O~ce Bwliiwl. Bta) ~'I F.R OU'1' i~er n~ m (m. ro.d«.v~p •a.a _ l u__?.lt. b_2_~'I l!~ . s.+ m(w~ ~.i ~~g .m. a.o.a..d ---i1~t1t~?-t~' + a:oa oeeurr.a eros ,e. oa~... Q.a a? m. ti. Nsad ~eee... 3PIfi~I." sza uaxw~ ~ n at n A1'I'E~1DI~iC I~tEDICAL F1'AFF PHY9. DIkECI~OR PHYS. ~ !fe PEiYB[CIAN'3 ~D~~ II o1 tt1q~ NAMB ('fyD~) Pa , Q 7( ! punishabl~ w~ f~r ~P~' t7~. BURIAL 7~D. D 23t. ~i ME OF CEaiF:T~RY OR CREBIA'I~OR1 ?3~l, ATIO\ , tCily, eovn. or ~ow~lr (,6hte1 . t,~p~ CRE`tATION~ :`r ~ . ~ ` ~ ~ - / . / . C SBMOVAL O ~ / 6 - ~ v..~~,f .~r~.• • ~~I~"d ,.~.s~- ~ !1. FUNfiSAL O~E ~`(i N ELC/~ UA, NL l.` • UJiDERTAKER '8 $jUNA RE LS . LI3DISRT '8 ~ ADDRESS GC L E A R L/~ / 1 ry1: /J ~ _ :~t TIO , C I~ 3 g 1 ' ' ' ¢ AE~fARKS: Te~et No. D1C.'Bulk'Bls:.:(!f yilii ~i~s L,Tr), g . . . . =~L , _ f~yf" _ . R P~ r f. ' 7 L ~ . ~ ~ . t. ~ it ? r•.• ' i'. ~ • . ~ . ~ . ~ y l.f.l t ' . ~ •~u•,` . _ .r'' J'` ~ - . ~ .uY-w..~ . 6~Y~.'f_ ~ • ' f . ~y~ ~ ~ ~ • ~7} . -J{. ~ , „1~. ~ ~`i • 2!~ Y•' ~ ~ ( ~ ~/f`" JS. ~ ' ~ - MARCH 25, 1976 ~ ~ ~ D~te i ~ ue~i; C~' +~~11 tQ:.~ ~i' ' . ~ " . ~ . ~ ~ •i~~., ~ t . ~ . ~ ~ •a~~- ` . ~ . ':-3. ~ TH ! S ! S i(1 t`rRT 1 FY TNA1 jNE A80VE 1 S A TRlIE A~0':}~i ;'I:ON ~ `.;~OF TH ~~R I G I~A L C~Et~ I F t CkTE F i LEL` I~v O~DE~t W t TN ~ ~ r - , , r - ~ ~ D! Y I S 14N Of Tlt~' OEPARTI~E?~T OF HUMAN ~cESGURCES, ! A. _ ~ . , ~ ; , . ' • ~ , • + • ' ~ , r , ~ ~ ` ` - , ~ ir ~4'~~ ~ y 1 C'~•a~~dal I, ~h~ef ~ ohn ~ . ~ - . ~ - - . . _ ~ . ~r~ ~ ~ ~ • ~ Yitat Re~ord~I? ~'~~.is ioh . . ~ - . ~,:.is+.-M~' r~i . ~ - _ ti- - . ~ 1 i' 1 , . • - a:, ~ . - _ _ . ~ . ~ ' - . ' ~ u?Y ~ Ti ~ 1 ~ ~ 19~ r111 ~ - S3 ' NIEU A1~~' kECW~~=~ sr.~~ pa~AA~a- ~,{~1t~'~1 t~(~C~ ~ ~ ~ Eklf.lEQ---~ ~caao ~ _ , ~ ~(~Q Q r4 ~4a.~3~6 30C!! t/VV PAGE v~ , ~a ~ ~ ~ _ . . _ _Yh ~ ~ ' . ~.~.d*~-~