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HomeMy WebLinkAbout0460 ~~.r~ . ~ ~ . ~F _____~~X _ ~ ,~~,,.~~~:i STATE OF MICHIGAN ' DEPARTMENT OF PUBLIC HEALTFi ~a~:l.10 . ~ 7 " - - - - - STATE FsLE NUMBER CERTIFICATE OF DEATH 0015258 B OECEDENT NAME Dit'~e~ber ~x M7E OF ~EATH (Ma. aar r..~ THEODORF. ' rIALF. s 8-14-78 _ lN1CE-p~. v~w. wct ~c.s AGE-~u~ ~~t.~ UNDtR 1 YEM UNUEA 1_DAY_ QATE OF BtRiH /Ma. Oiy. Y/J COUNTY OF UEATH w.~ /SiPK~hl /risl ~~ws ~ o~r's ~+o~ris~ w~s White s~ 70 __~se_ -1-- ~~_L_ -e. ~3ent,13._t 44? OqZ!? ~1!'!~----- tOCAiION OF OEA7H v5io[ e~rr t~ars a ROy~l Irq~TAt OR OTHER INSIITUTION t.~~, in~,e.le.r~...q.na~..~rr../.r~~ae•! (CAsc4 ons "'d'°"`"y'' ~N'"~ ~,`•°S ~ i 44? W. S~tr.n,;•brool~ ~e - - - - sr~u= a wiH rr~.,r.. usw (,~(~N OF WI~Af COI~NTRV ~~ARRID. AFVEp ~1atn•~D. ` SVRVN~NG J~USF ~NW.Ir, give maidr~~ namsJ rias ~_.iiwh7iv=H w ~ . ~ . - n .s-.. a n..~ ...,~ro„-: ~ Yr.bONIO. WV{J`~:E'~ ,aK.ti, us e~v.o ~~a.s~ ~~~~o w_ a_ If.i~h. 9. U. S. A ~o i~'qrri Pc~__ F?_i zabe*h rhlnn ,2 NcSTifU:k7A_ "___.z~'___-~ _ ' _ " " " _ _ _ k~ r~~.~,~~ $OCIAI SECUR~TY NUAIBER USUAI OCCl1PAT10N (Gire k%nd n/ wwA dane dunny nwsl ol KIND Of BUSINESS OR I~IWSTRY e[awa~.tic waR.ny hh even O n•rin0/ ~„•r~.E~~., ~ 1 _r or . .~5.~,~~.~F „E,.s 371 05-583? - --I~4~ Supervisor - - - ,.b Chry ~ p ~ - ~ ~ GURRfNT FiESs~NCE-SIAiE COUNTY lOCJ1l1TY f sp~ ~~rr lwitSOr RO. '~,1 ~ 'I STkEET /WD fiUP1t8ER fChecA ona 01 r .,~s~.y,[_j~~.~ ~.,,,5~ 402 W. Sunr.ybr ,s.. Ii±ch. ,~b C~~kl~r8 C 1~.~ ~y ~s~. FA(HEH-NAME rwS~ ?~rc,a[ twSt MOIHER-MAIUEN NAME rcnsr tr~ooiE lwst ~ < ~ ' ~ 16 xghry D1 ttpnber K_athsr~ n~ _ _ (unkno•.~m WFOPo1~.n^L'irS'• L'._ 7~ @~Y~DLYiY~ieYlb~"~"LINGADD^nESS s~mtronRro~70 QT/ORTVA•: Si4~F tr C~r.t~TatiS 7 1 ~ ~ M~.~ ,~.rs~,,,,~,,,~, ~ J.~ r,~r~, ,e~ 40~ W. S~n~brook FoJ~l O~k.I'I 480?3 ~s~ ~o ke.ti~ ra,.... w~ .,,s a.n Y'~ W~~ 19. Ii~VAEOIATE CAUSE ? (fN7fR 0~![YONE CAUSf PfR Ll.'!f fOR (aJ, /h/. AHD (t/./ s~~` P~T ~ ~SUDDEN s~„T;~.~ n,E ,s, SuunEN r~YOCARnIAL FAILURE _ u.~EM~ ~vG pUE TO. OR AS A CONSEUUENCE OF ~~n..~ wr.e~. m.e~ .~s se,r~ CAUSF IRSI ( L~ - -COP.ONARY OCCLUSION------ WtE TO, OR AS A OONSEUUENCE Oi: ~ k+tena~ set.Nw o+~-~ ~a Ws~ • ~~t AP_•TERIOSCLEROTIC_ }lEART UISEASE i _ _ P'r! - w - _ - - - - ---~W-AS CASf REFERREO TO MFDICAL PART fF 07HER SK+ti1HCANi COND~ilOt15 e,n~weu.+ cd+.+..a•w e.. a.~, e..r . oe ~la'tQ b[~~n! y+.+~ .?i.~~ ~ AUTO: SY /Sperily Yes ~ (Specih Yes or Nol ` u /Wl fXAMIhcR~ CORQ\A~tX ARTERY_DISEASE _ ~ - - - - - - - z°-_ -I~U - - a~._ _ AO ! - RACE OF OfATH W.~... w y w.~w.. ~ 24a. F NOSP. Ofi 1N5T.. rec.~s OJa. ~ Tns u,- se+~.~-e ~w k~.r.,:.+a .n ti: ta + r..' .s ~ e: ? csu ~..w~,~ ~~,e.e.K.~ f~~hl or:i..+.. R.. rs..t~.e lSnc'e~ly. ~e..~~ ]2s ~ ~ 2?b a~` e. w tn. ~..s a e.,.:+~ a-+.. ,~,t.•a .,i. ~ 7,+0.. ~.,.,.e. e..~, a.cy...s .e w 23i. le W Ee,r W 1wt ?.rr.'r! e? o_<...uf ar M~i~. e• s~1 P~ sN 0. I~e. 4b ~~O N~• +^O A.w ro 4Y er+se',t s~a~sE Y~ cs.lHJ ftNtO ~ ~ ~ / n (Signatu~eand7i(tel~ '3'L.t'Z'~_ ~'~L_~'~~~-_ Q /Si9nalweand7itltyS Z a DAIE StGN~D /A1o, O.ry. Y~.~ lIOUR OF cA H V Z OAiF StGNED fMo. Day, Yi./ HOUR UF DEATH =.-r l~ R-15-78 _~2x 12 t 30 ~ P 24b. 74c ' M ~j~~. °L - - - - - x ~ - 1. S~ s ue' SU~ OP A11 tN~JING PIIY S ~ClA'~ IF O1HLR TMAN CfRi1F~ER (I y p ewOi~~~t/ ~ W PiiONOUNCED OfAD /l.t~_ p,~; Yi./ PRO::OUI:CEO DEAD /Noui/ 2~ 24d. UN 2te AT M I.At.tE ANO A6URE55 OF CENTIF:ER p.~~soa, a~ utu:u! tx4v.ksn, (Typeor Frm!) zs F:O~qLU E. ~;.~AL'FF U.O. 28437 GY.EF..`:FIELD, SOUPHFIELD,_MICHIGAN_~+80~G_ = S~a:.~~`t Hu's. w+~,ru: DATE OF 14JUNY //.fo.. D~y, Yr./ HOUR O~ ITiJURY DcSCH:Bf t10VY INJURY OCGURHED w rew~nc, wvcsr ~~^.~.1• 26a - 2~- - - - - - - - - - - NlURY AT WORK- PLACE OF 1!+SJU(.Y ar n~,:-.. 1...~.. s'•<.•. 4~..~y LOCATION STMFEI OR R i O t4 OTi. vat~GE. W r_•r.•.Sa~:P STAIf /$pec~ly Ye~ or ~tol wa.y rc /SPec~1y1 ~ 26e ?6! 2oy - - - - i - - - - ' EU9iA(, C~tc•I'A71C~Y, Ri7.tOV:.!. OiNi/1 (SF~uh~l CEM~.FRY UR CREtrATOr~Y- NA',.~c LOCATION ot•. v.,~cG~_ c~ iJ:•.sr:~ StwtE ~rt ~ ~ ? ~ Troy.Yl^h 3r.Sa~~- I1d 3~-._ ~z_ i~~~. t~~hi e Ch~p.~l_ _ • 'I ' ~ ~_u3i~1'-~ OniE I•Sfo.Oa~ YiJ NtiEtE OF fAQUTY ADGn:55 OF fAG1UTY - -x~.Z~l PP:r~i . y z~a ~'1~• 3~s ~ 9~8 ~s., A~~ii ev . °1"3~ u0?"° zse i t`~ jLB~ '~i . ~2q r., Woo3r iff- _ ~ t ~ - - - - - - - - - - - - - - fUtiiFlAl SFh~~CE UGtt:°fk ltEG~StR~ r J ~ D A T E R~ C E I Y F D B'f P.: G~ SIRAR (J'Ao., D a y. ~ N (vynalu~~ /y lS•ynaiGi~~r~ ~ Yi./ a ~~,~ai ~~_D-~~'--- -~L,_ - Iz9~- p- - -----~29G Al2~SC 16Z 1978 _ _ - - ~ ~ I l~ere'Ay certify that this is a true copy of a record on file E in the O~fice of the City Cler}:, Royal Oak, Michiqan, as attested to by the seal of the City of Royal::Aa]~~ embossed hereon , , ~ ,zj~i. : - . - , _ f 6 ~ - r • ate D~put . Re~gistr~? ` ~ ~ ~ l~T9 ~'AY 22 A!1 9~ O1 . ~ ~ FItEO AND RtCOkIkO ' ' Sf.LUCIE COUNTY.F A. , ~ CLERK C RCU~T COWt ~ ~ RECOkD ~'ERIFIED~_ - ~ 44.~11_0 ~ ~ ~ - , ~ ~ . ~I e ~ ~ 1^L. ~09 460 - . ~ ~ ~ - ~ ~ ~Y~-- ~ -~.:f.~ E€e ,y~!kd a` : . . ' ~ . !