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HomeMy WebLinkAbout1321 Goldwire ~ ~ ~ ~~#9398 01-23051673 _ _ . . _ y F c~~cw~ oR c~TM ~ ~LOata~ R,?n . O i s. Ooos Nv?- N~UAL 1<NC! (wwr aw.w~ M..a v : w.Iw.. w.. ' G ~ - / . sr~n ~ ~ cou~nr ~ ..a«..~. ~ Y .+.w ~ .~w so,.~.~ s. wwrn of cmr ar ..aw ww. ..M. .v..w' ~ - ~ ~ =~,Y ~ r_ ~ ~ w??tt Of ttt..~ .r rrurs~a ~a~..a.w • ~Ttif~ tr ~..1. s~w ~..e~..~ Ko i ~ Q~t~-~ . ~ A-rz ~ilt~i ~ ~ ~ ~ c~~ w t~w+i.~ c:..~~ ~ a?n i ~ cn.~~ cY..r? oF ,t_ a_.~ eF,?ni S- l 9 ~c a. cow~oa~?c~ w~uuEC oi~vo~ r, a?rE o~ u~ ~cE~~. ...y ..p wioowEb, ~e.~.t.. f r - ~ QE 2 ' o - --1----- US{~ALOCCUTATIOlI~o~M tW t wr~ IM. K1ND Of WSINLSS Ot IN- 11. tTHIIACi ~e Mup ~ 12. CITIZEN Oi WMAT M1 d~aMli~ utw w~y ~+ttn~l 01lSTtY ~ ( • OUNTR111 ~ .1, , 1 F~ it ~ ~ ~ Z 2 4'~~ _A ~,Cy' , - . :ATHN'f NAY! r. ' ~ I OiHii'S ~1 MA1iE . i\ S -n ' J l ~v~ ~ ~.J~~f C~C---Gt.C~I_-i-~-~_. ~~/1 i _ A3 DtCEASEO ~t IN U. S.ARMED FORCESt 1~. fOC1Al fEQYR1IY q. (NfO~MANTS StCNATYti ) lf~~ ~ nL~wl lu 7~. Ow wr ~ A~w ~t rnW) NO. 0~ _ ~ • / [~-2I'l.t.~ AD~~SS ~ _ ,A • I :AYf! OF DiAiH M~ICAL CERTIFICATION ~wta~w~ ~twRN yy~ 1. OISEASE OR CONCiTION % ' 0~1~1T AMD OfATM .ls~ fR oiucnr ~wc:Na to oEwnr~. J..l.~z ~~,QL ti~~ ~1,~ I?-t.~,~.~, C,c Q..c.~- - ~ - t.~ . ~ ~ ~wrECECarr c.,usu ~~1,~(~. t~, r.-t.t"~ ~ _ j R-u ~ y~ lbrir! iowl:tfo*a. 11 ~w1r. ~(q~ui TR ( ^ ~ y ~s~t ~p~fn. riN b tA~ ~6oav ea~w (s~rbF `'t~~Q.~' ~ (1 ~ rj ! f ' . . r ~.+iR ~b. le w.sw~ tA~ r.t..rr*a osw Is.t tr u~ rl kw~K Mi~f~~ M DUE TO c t- A.t ~-i ''..J A tl. OTHER S16NIFiCANT CONOITIONS • ~+d iM1+L CowJitiwi eowtribrtjw~ te tA~ d~st~ h~t wst fdstel te f11~ d:raa~ o?_e~wditiow atwiw0 ~stk 6ATfi OF O?EtA- 1!?. MAJOt FINO~N6S OF O?ERATION ir. AU10Klf 1 ?ION • ~ ~ •cs ~ ~w~_ Pt~eb! 1~1~1 lls. rLACE OF INJURY tar.. l~ ~e ~Awt 2~~ (CITY OR TOWN (CO NiYJ [StA~E1 ~cetn~MT . t~i . ra ~7~[,.'11./ ~ e~U. K tuLy? i , ~ / ?:~}tlDi ~ ~P h ~~~'~,i ' ' ~1..~~~ .~~~L. - ~ ~ f ~-i_ ~ ' Tl#~E IN~W) lln~l Ir~rl 1 il~. INJURY OCCUlRFD 2~ . NJU Y CU . Of Mll[AT IIOT\Nit~ ~ ' ! ~ f~'~ : ~ ~?lJUltr J'' ¦o~~ ? .t.o.¦ ~ -+vL ~ ~ Ll" / )s'Wn-t.(:~ ~~''"~'~s~et~ ~~t ) ~~eby a*t~v,eboe 1 at~e+~~ i~"de~d~/~ n J'18~ to J, 19Z"1. eAal / loat aon tA~ dcceaaed , 'ive o+?._:__'~ ~ ' ~ 0 1 of~ea c?c ~m. row~ !Ae cnusu orul on lhe dale afated a5ore. S16NATl1RE tDeS,~ or qWt •tri. . ~ n r !k. DATES16HE0 , , ~ • ' 4% C' ?~.l 2~> ~ '~~~,1,~ - , E 4 ~ /.,f. z / _ ~ R 1 A t, C~EMA Nb. OAiE Nc. NAME OF CEMETEtr OR CREMATOtY 2W. LOCATION (Glt~, tewn, or aount~) ~$Mte! ~ ~ ~EA/OVAI yp~.~tll • . ~ , l ~ f ~L?_~___~~'~'' . .v c~ ~'??-y.-~ . t_,~ ~ ~ • f tEC'D ~T IOCAL t ST 'S S~GNA~URE if. FUN l CIRECTOR'S SIGIiATU~f ' ADDtES; i RE6. 1 r ~ • y~ ~ ~ , , ~ . , • ~ } ~1, , ~;tr' s '!,'i ~ ~l'. { ! . ~ ~ • . 3 . ~ t I ` € ~ 1 ~ nyr?hy rr!f~+~~~ H1~3 t0 ~ S 1fUA A/1d CO~fACT COPY O~ 1f1E ~A[.1)~ ~ - - t~?e ~n the St lu~~e Gounry Health Ospert ~ ~ ~ ~ ~~~~a ~ • - ~ rhe Sr Lucie ~ ^ ~ , . ~~^:P;S r ~ •r ~ t• . , ;P, . . ted ) ~ ~ . , . " . . ~ ` - . • ~ . r • ~ F • . - - ~ .I. . • ? , f:..~; •i ~ . . . ~ 3 ' ~ ~ . ~ 'Y C1 ~ ~ r-~'~~~~' ~ 1 ~-=;h'~`" - / . , ~l~ee fleoul~. : y RF• i - t ~ : ~ ~ ~493y~ -7 ~.v ~ ~ •~79 2 ` ~ s. .,c. ~ ~.1; ~ F~~ED F~:, k~~~r•~~?: gi. lUC1C i.'vU~~ Y., ~ R4GER PG17P Ja r~t~ ~ CIERi( C1ACU11 C'' ~j ~ ~.r.L__~!-Lf # . k-Cr71'~t - s 3 ~ ~ _ k . ~ :.«..~11 ,.,~.1 ~~1