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HomeMy WebLinkAbout0188 - - . ~ _ Cert~,~iec~ Co~r,~ of a Deatji Recorc~ . ~503'79 STwTE OF 1LUNOIS a~~~~ n?e ~ acWSTwwTroN 3,r~~ - , . ~ «ur... ` i o MEqICAL CERTIFICATE OF DEATH ; HU4ABER - ~ • ~ i DECEA3[O r~w~r woo~t . ust tio..T... o.~. ~iu IKARIg M. BUSENBARK ~'emale 3 July 22, . 1978 IMO ~M (T~ ~ n~tu%~,~YlA~CAM IOIM OR O~lC[N N TMOw, jv~f1 UMO[R 1 ~CAII YNO[R t OAV OAT~ O~ N1~TN WO . o~r. ~a~~1 COUNTY OI OSA~N s,_ White bMoericaa 65 s. M4Y 1913 Her?Y'Y c~rv. ~orr, s~•. ow wo~o o~sTw~cr wur~iw MOt~ITAt Ow OTNp tMfT~TYTION - w~ra p~ wo~ ~w u~w[~, ~Wt 1~~at* M~wv. ow ws~...~.c~r? . ~ •rowu~M~l an~r[w w~t.r~~~.s~~ 1~~acn.~ ,p_ t~eneseo Nemmond Henry Dist. Hosp. ,d. inpatient 3TAT[ O~ ~IR?M ~t~ Mor CI~IZtN O~ 111MAT COUNTI~Y MAARI[O. N<V[II M1~I~It1[O. N11Yt O? ~UI~VIVIN4 frOU3t /~~wtr M~r~, ~i r~rt1 u~w w~rccouw~w~l NIDOI~[O.DIVORC[DIV[c~r~1 8. Illinois 9. U.3.A. ,o. Me~rried Robert Busenbark soc~w~ sccuw~*r nur~cw usuw~ accu?wnoN K~NO or ws~NCSS os ~yousTwr U S NAR VCT[RAN www ow owTCS or scwv~cc, W q:~+ol ~z.3~-O1-3630 Home M~ker ~se. ~ ~ ~x. N~ ~sa. - ¦CSIO[NCE sini[t ~w0 wurK• c~T~, ~o~w. ~0.0~ wo~omsiwKT u0 Nf10[ C17• COUNT? STAT[ W is.rol 516 ii. Fearl ,{b. CjeaeBeo ,s~ Yes Henry Ill. FATHER - NA4If MOTHER ~ MAJ(JENNAYF r~~f~ woo~a •w~t 15_ Peter Peterson ~ ,s_ Haunah Utter IN~0~IYANT'S 316NATUR[ • A[I.ATtOMSNI? MAlL~M6 ADDI~CSf ~f~~lR ww0 MO O~ O. C~T~ O~ TO~M.1T~Tt. I11~ t~a. RObeY~'. BL18erib81"k • ~~it18b1l~tld 516 w. Pearl (ieneseo, Ill 61254 DEATH WA$ CAUSEO BV •r+~oa~rwn ~w~awr~~ ~aw~cw or.~~ OHE c~usc ~cw u~c ~ow ~b~. ~..o (e?) ~{1~{{MON1t7 a~100~~~M PART 1. ~~~EaaTCCwusc i,~ General debility towprro~s. ~s ~wr, ouc ro. ow ws w coMSCOUCNCC or YMKN WVE IIifE TO - rr~awTE ewuae m el, eu08 ~Llli@ID~.B Acu4se 9/14/7? ~a MY o6 ~ IVWGCAUSE I/~ST. OU[ TO. OR I~S A COMSEQU[MC[ O~ p~'~ p 03 S ~C~ PARTII. OTHERSIGNIFICANTCONpT1QVSteorar~oaseowtww~~~wrooc~n~~enwvwei~.~nwe~enca~vwn.~un.1~1 AVTOISY r~-.aw~r..rweo. I•es~wol ~ .as.rsi*a.r...c<.wa _ K~~ ~ 19s. NO 19e. 01~TE Or O?ERATION. 1i AN? YAIOR /INDIMGS Of p~ERATIOM . ~ Z~. • ~ ATT[NO[O TME I~o+rw. o~• •[~wl t~or*w. 0~~. ra~~l wMO t~fr s~w ~ur, tror~r.~. o~~. •~~~1 MOUR Of D[ATN O[CEASEO ~ROV TO ~ /w • ~ ?la 2~+ 2 Zib. 22 21c 1 r8 2~e. 2 0 A M •o ~r[ ~[sT or r~ AMO~I(~4[. O[ATN OCCV~~[D A1 7N[ f~Yl. D~T[ ~MO ~l~C[ ~ti0 OY[ t01M~ C~Y![NIlTAilO DAT[ 41GNED IrOwiw. Ow?. •t~~l z2a y~„~ ' Roberto S. Puentes, M. D. 2~ 7/22~78 MAME ANO /10ORESSO~C[I~TIIIEN Ir+K o~ ~~~w~~ ILlINp15 LICENSE NYM~ER ~ z2~. 100 E. Main St. Geneseo, Ill 2?a. 36215 NAYC O~ ATTENDING M~YS~CIAN IF OTNER TNAN C[I~TIf1ER ~1~?[ O~ ~~e~wtl • ~ NOTE. 1~ AN INJURY r1A51NVQlVEO1N TNIS OFAT?1 23 TME CORONEII YUST !E NOTIFIEO. . ~ •UNIAL CR[MA~N CEV[T[NYORCREYAYOR• A LOCATION C~~rowTOM~M f~~i[ OA~[ IYONiM ow~.+tw~~ j NCYOVAL IY[C~ 1 ~ ~ za~. ~i~ 2an. Oek~tood 2~ Geneseo, Z11 2~ ?-24-78 ~ ~UNEPAI NOME NA?~E i~w~ar ~no ~.u.~~[~ ow w r o c.rr ow ioww sT~~[ :v . ~ 25a. MYerB-Wright l~neral Service 405 W. lst Geneseo, I11 61254 ~ suNENAt O~M[CTOR'S SIGNIITURE ~ ~u~~~~~ w~[~~o~ s nuuo4 ~~carf[ wur~[w } z~ Joe R. Wright P'S372 IOCAL pEGISTNAR'S SIGNATYRE OATC RECO. w LOCAI AEGISTRM 1~4MTM. pA~. R~I~1 . Arlene L. Ray, Registrar, by I~yrtle J. Bessant ~ July 22nd, 1978 i ~ ~ ! NBRBBY CBR PlFY TNA7' tbe foiesolRs tt • tnre aed eosset topy oj i~ rocord Jo~ tht decedsnt iwmsd ~t /ten~ l. t~d th~t tb/i record w~i ett~OlltJrsd ~ed J11ed G~ ety oJJkt lit ~ctoMeett wttb tbs on~~~ ~~r.°li Y/t~l Rseordi Act. 4 ; ~~ri;?= ~ ~ . ~ : ` July 22nd, 1978 y~ ~r ; Registrar DATE ~ :~•;d,~^.~ ; ; ~ "x' .~2 : . Genesee -g=' - '~j`~ : ~ T IlN~of~ ~ ~7Cfil~.~'ll~ ~ - _ ~ ~ . d _ P,~ - s Thr oslsln~f ?tto~d oj tbls deadY /s pe~miet~tly JQed w(tb tht IL~l~~ DdP,~It1'X~,~~1~ rUBLIC NBALTH at Sprl~raNeld. Coa~ly ~(e~ks ond lottl ~e~ttb~?t ~rt tuthorlstd to n~ate teitlJkaHont fro~ o~~s~; ~ecord. Tbt lAfnots ttatutes prorJde that r~e ; cutlJfeetlo~ oJ ~ dnth rseord by the Depeitinset ojPabllt Kss1t1Y, ~~~p elt?k tlrN! bs pifwio j~e(t trMtnce i~ oll towu a~d pJ~cer oJ the jeett tlYusfn tt~tsd. ~t'• j~ ~ `r~t: . VR-201~C /1978) OFFICE OF VITAL RECORDS - ILl.IN015 OEPARTMENT ~ifr OUBLIC HEAI.TH - SPRINGFIELD 627~ 1 ' . _~r 3 ~ ~ .n . . , - ~ ~ . ~ ~ ~ 45t~3'79 4 ~ •.319 J!!~. - 6 i~~ 12~ ( 9 ~ FILEO AML~ F:CU+~i'.EU _ ~ S ROGER POITRASA CLERK CIRCUIT COU~i ~ ~:11C~~ 1 ~ ~G~r 312 ?AGE ~p0 a ~ _ - - - - n: