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tF -33 ~ STATE OF MICHIGAN
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qq. RATE FiIE NtiMOER
O 13 S 6 S 3 B ~ CERTIFICATE -oF DEATH 4s:~~43
OECEOENT NAME • west was Iwst Sat W?TE OF OEATM /Ma. alt 1tiJ
John Elmer Elliott Sr. : Male a.Marah i ~
RACE-«~. war. erati ~.v AGE-w Mw.r V DATE of 0111TH /Albs, aft riJ OOUN1r OF pEATN
~ ~ Jan. 9 1 2~ Oakland -
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o,: ,,.Wllligm Beaumont Roapiteel
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stwts a ewn/ p?sw r 4tSA p,~N OF ww?T DoLIItt11r nwewsa eeva rwwa. sLAMNNO S?OUEE /I/widib ~Iw wui/bw w,IMI
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o w E. M1ahi RM s. U. 3. A ~M"oowto. oNO~uo ~ Batt A. Ki!18~ ,at~.~ew
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EOttAl SEQNSTY IItMASER UStIAt. OCWrAT10M ~ ~ ~dY?in~ roast KMiD OF OUSINESE 011 MIDtISTIItt
369-20-0?62 ~ xe gir*ren ~ T.L,_~ Chr eler Cor .
t%JIIIIEtR RESIOEncE-srAtt oo11HTr uouLLITV elsoa otr a z e ar AND N1~
~0'°°E 1681 Maple Lane
tae. M10!'!1 n usu. Ogklar>~rt ~s.. TM~-a ~ ~s~
FATHEII-NAME hest ~wo~i twst MOTMEII-MAIDEN NAME west root ufr
,a John - Elliott Bertha - N/A
~~T 8 O MARJNG ADDIIESS steESt oe Itso ea, amr a taws srwa a.
;°°r'°'~ ,ee. ~ ,•e. 1631 Ma le Line Hazel Peres MI 48034
w~.al wvs. 19. MAMEOIATE (EIY/H1 Or1KYO1MF C.41/SE PEit [HIE fOIR I+J /sA AAm /dU r.rIII slae....Ir w.r.I
:t ~ .ART 1~ y J N sI~'- [ Ate'-Ttn iDl1 r~ ~ . ~C A~Co~n a ~9r~~?~s i) i ~7N; Yt ~1~1
IeoEareo DuE TO oR AS A CONSEOLIENCE OF: I rr+.M qi.....w w.Lr
wrss ust.
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ouE T0. oR As A OONSEOUENCE oF: I....r.....~...r«+..+~
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?ARi M 0T1~1 SIGNIRC/ufT CONDIT1011S-Crrw ew.w r .Iwo M .w NIIII. r cwr .iYw n rwet I ALIiOPSY /Spsuiy Yis WAS CASE REFERRED TO MEOIGL
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~~91s 1~ •~K ~ra~ ~ w Ab, ExAMINERr spwr xa o. Ab, -
R/1CE OF DEATH .r..q tlwa F OR ~ t~. ~ sr .Ilw.~w s.I r w s oI.4 ..I.rI?s saa
I.~rt ISPa*hl apts... es?. Me..I l~iP.e+hl rorcr,
22.. ~ i2b. • ~ _
e..1 ~ a..i. bs..I a...o.r swv w+~w • ....+..rw .oaww x ry _
2 T~ .i. NIt .I W~ti M M Ina UI. W .bc. w M r rsa 41. MI MIiI M. M r Mr t.oIIM MMy
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al /$ipfl~Nr M1d T~ ~ ISgntYa aId TiWf ?
~ ~ OATS lea. ai. Yrj HOUR OF DEATH 3/~,~/~ pp i DATE SIGHED /AFa.. a1: n./ Noun DF DEATH
N 230. 3 7 23a T~ M g~ 240. 2k Y
NAME OF ATTa~IOYiG PHYSICIAN IF OTHER THAN CERTWER /Typt er PYiuU 2 ~ PRDNOUNCEO DEAD /Afa, Osy, 1'i./ F'RONOINiCED DEAD llbvq
~ 234 H~J s h • A 241f. ON 4.. AT M
j NAME A41D ADDRESS OF CERTIRER MIIts41MI Oe MEDICK sxwwrtw I t1p. av P?iny
2s A.M. Hauser, K.D. 3601 111. 13 Mile Sd., Royal Oak, Michigan 48072
wot, sucloE IIOM. wwtuew~ QATE of w~uRir /moo.. af. rf:J Noun of INxan oESCaeE How w.RIRY ooa,RRED
i oe haoen uwst. ~svK+b
26.. 26b. 20e. 204.
NJIRIY AT WORK PLJICE OF IPIJ.lfR1f-we ~L.a ~ ~ e.wn..Iio. LOCATION sresEt Oe ws.a,Ia at?. valwfiE Oe towllOr stwtE
` /Sp.a/y Ybt a II6J e•++•a ISP.aTYJ
20.. 20t. 2
f OuisAL. t31EMAT10N. REMOVAL. OTHER CESIETERY t1R t71EMATORY-NAME LOCATION on. vrtwaE. a rowllpr stwtE
C Burial 2,6. White Chapel 2,~. 7.'roy, Mlch.
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E DATE atc >,:J NAME of FACILITY ADDRESS OF FACILm Hate ar ,
:~e. 3/22/?9 :e,Ashle~? Flxneral F ~*e z .3~ E. Woodrt.~fP- MI 4A030
FWlERAL SERVICE LICENSEE REGISTRAR DATE RECEIVED OY REGISi11AR /AkI. A.r.
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J m.. Marth 21, 1979''
I hereby certify that this is a true copy~of a record.on~file
in the Office of the City` Clerk,. ,Royal Oa ~ , t~,
attested to by tZie-`seal of the City of Roa 3 t 4ssed
hereon. 7 _ .
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