HomeMy WebLinkAbout1906 an~7s35
t OI' NisR ~ .I QS ViT 1pw~w ~ t T ~ r ~ - t, i
. . ~?J!!N 1 1979 , •
1 tJl V~ rK W1~yJ ~ t ~ •fy
,1 ~E~7.'^E HEALTH ~TIFI~TE OF DEATH z
~~t~t1~.IVH;)` ~~'~ttiX Certi6t:a4 Ha..~..~..~.".~..7..-.Z..~...IJ...!_..t..7... Wis.
•
1
DwTB F1LID '
~ ~ - C _ x
1 IrA1~E OF ~E -II~~ Lr ~ ~~s C -
DECEASED
~..N~ _
- . _ or Print Firms Name Midd:r•[~arne last Nano • '
i ld ICAL CERTIFICATE OF DEATH (Te bs JEIItd tin b1? the Phyricticn) • _
\ ~ \eH' ~ ork City T 4 Xstee o! liwl.ni ar Ittstitt:twn. If not in iw•pn:l, •uert addtr., ~i "e~~-`
YLAC!
UEATH a,~~~~h ~E : Io~3 Ems i ~ 3I s,'
1 ' Hear AN 1. 5E>< s. APP 0171~ATIi AGE ~t ,T-
ta. DATE AND = oy+_..
IiOUR OF I / PD ~ >t
DEATQ ~ I /
>E 1 tit
~ .
s.:
t...
,r-cN~D N--~t
t 1 HE81~Y CERTIFY tha! (I attesdad sie decaa•tdl• (a etaQ tv5sairatr o1 iii. iaaitution atteadad tie detwrdN (Dr.. . r.-
.lteadad t4 deceaeedl• t.ae,.V G.~ ! ts.~([. to.._(.L...~ ~ "....i8.77.~ i.a .a. ? hj2. alive a ,,~~1[ os..-~ , ~ - ~ s~ =*~Y
_ f
-.t..
I ) 5.~ (artier eeRifFt yrt traosatie iwjurT or OaieeniaR DID NOT Plas us part is eauaiat death, and fiat iaath did sqt Decor b W oaaaal . `
i manner and a+u dae eatireis to NATVRJ?I. CAUSES • coon ata ..orts dre do ast f See tiu Iauurttetio. oa reoerae . ~ : ,
.
.T
.4'
K' ~yt~
ttt.aaa iq lard tits f a -
df d_~~ IL~ SitMtur C~,.a -
~~JJ~
,
l:.n.e sa Pisiieian~~!!!!N .-f--~- ^ mow/-- ~.J~..!~..~r~l....___. ~ ......_~~~.,/------~-a'•s-.. ` ~ e:`.3'
.
7'ttne ar mist ~
_ PERSONAL PARTICULARS (To 6t ` '
filled is t?y Futaeral Director) -
+ ~ . i a. State . a Coasts : e. Ci or Town =r:
.
t ~ =d. Inside tats liatiu of •'7C• -
I ' 'I ~
rsuwl. ~_''e_sv _YD~k___ ~ $~~'~_~_~_--------------!bleu _-~!~R~ ;~,rs ~ ' . N
c e. Street and base nrmier` ry
) t:..a'DEl~CE~. - - - i f. APL j t. LmtW of residence or etas in City of ICew z~s,
- D6 3~ Sr ~ York immediatds Prior W death. ^ .-%:-?'i~'i-.-=.-.
_ t. SI`GLE, l[ARRIED. WIDOWED a7 DIVORCED (Write io word) t!. NAYt OF SURVIVING SPOUSE Ilt wife. rive snaideo natae) ..?+'q'~
.vQ ~R~4 GA.Pc~,a =::--}:=:fir-.;
1liontil
to. LATE OF IDs) /Year) j it I asst It L>CSS tiara I das r
BIRTH OP Il. ~ at hrs. or s•ia.
1-rs. I s
USUAL OCCUPATION Iliad of v~srk rose durint taaat = ZIND of BUSINESS or INDUSTRY 11. SOCIAL SSCURTt'Y NO. -~~x``c y-
vrorkine dfe, even U setind.l . may, •
~v_~~/esa/e f'.ro,ov~ E - = P~oo_ ~E ~'NO~s% 3D -03 - oa ;i~~ -
1 BIitTltpt.AC>V IStata or Forsip-Cosutrs) 13. OF WHAT COUNTRY WAS DECEASCD CITIZEN AT TIME OT DEA
I ~ i. wh'Y OTSER NA1[EISI Y 71iffiC>a DECED=N'T WAS Y,~fOWN _ - ° i3`,~ V 7` .
f'RFD P/Sc N A C FR F D . P/SGA J1I ! ~ -
t >vw>rra OF FATHER OF Dt?CED ~ - b'h-
ls. YAIDlt?I NA1It OF MOTHER OF DtCIiD>rNT ;
Esc i O~PA ~ - ='~~s ~s
-t,L NA]IE OF INFORlIAAT~ ~ k RELATit't\SHIP 'c ADDRESS : _ _
i ~ - ~ Th TtE ASgit j .t'7 (fire) (State) .
8 /4 ~ -
~~'.°/Y/ 4/?t~) • ~ w ~ e ~ 063_ ~0?3/ ,jr
' ~ L w td E F CBit ETERY OR C'RElLATORY : 4 I.OCATIOII tClty. Zo~ra; 8ytta Apd CoWstrn / : t DA d Burial ae Ceasat ba ~ ~ ~ i ~ ~
.:a. F'L'NERAL DIRECTOR
f-:i REAP OF 11TAI. KE('OK1?S p : ~
T E CIT - OF tiEVti YORK ~
- - - iTtii if-t9 C!!si11/ i.:::a ire alayG:2t~ ii R ~,x: ' - - - - ` ' - - -
S i _
j~~ ~ _~~w. A E ~~y~t3 • ~ 1~ ~ _-ter+-~ " T
~ Z _ ~ - tit
_
• .
-*s
T'r "t'^°-•:~:°r•= Fti•does a••t t:t3etiie Ia :'':tl~ tn::h of ~t stat4a..tt:s mttCe thcrtroe. 3s tw, inlrrte :s ~ r
the lasts ILLS aeert t.roa~ t;.r low.' 'c. ,ii.-~,a._. ~ _ f
t` 00 NDT ACCEPT cN1S T~wNSCP3PT UNLtsSS THE RAISEC SEAL•OF THE OErARTItfJlt Of NLTALTN f. 'r ~
1 -
AFFi7.E0 T.`IfiiEON: Y.FPROOICYIOM OR ALTERATIONS ARF. PR011181TE0 !T lAtf.~ f - ' r (
1117A ~Int n t
~t^ ,
-s 1 J ~I~ ~ • L I
4 `f' e
FILEO Rk~: ^iCGh<<it)
ST.LUCi~ CCU`fTY.Ft:..
ROGE?~ F't7iTA~S
CICr?K CIRCIJIi C U31
FECCRt7 ~ "'~r~~~!
c u ~
- ao~~ 310 ~,1f.~ 144