HomeMy WebLinkAbout2521 - ~
1
t
~ -
t
- ~ -
x
.I
`t~
4 ~jF
2 ff ~ 'J
~ ~ 1 ri
E
L
--i
oEtl~ititA~ o~Ar~Nr of ~K~ sen~s - VITAS ~~conos secTtola 0 1~•
iATE COPY p~~~~
EA~Ep A $UG$IiB I sEx DE/?fN • rEiw
: sale a A 10 1979
" +c~ a , wda AMieM rfQttfl, fret w
''E ~ OIWrt I1IES1. NOI SI'ECin. ?IIE~11T01,IC/w. CUlAII ETC wfp~1(~S+(SPEGFr~vf.SN011
MO!
White . No - c - s Yes
Ace of A o0lurr . To+walt cnr C IID6~ITA~ oil rr trESOetcE. crrE s,T~r AoouESS D p
_EAM
_ 1larico Phoeniz ~'TM
t Jose h's H~oa ital ° ~
~"T _ ~
- ATE Of ar rEM AOE BEAN i Vf0E111 rEM i VfOEfI T wr MAINEO. ?EVEI1 YN11iE0 SIJ/tVNNII - i wsE. GerE tMieEJt f
wt rwTtoAn MOf _ OAVS NR!<- MN wDOwEO. dM011CEp pPEGfr1 aP0115E
s 13 191$ p:.60 s - c . Harxied ,o' Pleasat H. Conner
" TATE OF N UOt ift UiA, fnw. QoufY>A Of IEWr ~At N:T%AI111~. OCCtIPAT10N lo».eefr r011D OF SS OR NO115T11Y
7JiTN Y +c=ualwt la 22 ,.A a+ N.~rntB ce~ tSs ~~a o
~
0
~ • i*lTE • O01ntr, C tOw OA Mr - 6 rr COOE _
~~5 Arizona Harsco a Glendale SS301
> t BEET u~IDE CTl ON ATION IDIM LONG N PRENOIq STATE
9FD 1fpfRNW (gVIErY Ofrfpl rEAN EO/Tt4 Mrs OF
4902 W. Bethaa Hs.# Y$a ,Sa 1'.~0 ,0 9 ,T o~rida ~ -
:5 = AT?fER'$ A FaAr ~ root/ - C aAST T ~ • i1NT a Mf00tE a af?St
-:F(KiMANT's~MIATIXE pCE~ TO ~TNO GTr AtfDAAfE LM OOOE
~ Dorothy A. Rice 21 wife ~ji902 W. Bethany Hs. -#15, Glendale, Az., 85301
' `-•tWAE,C(ENATWNi. GATE _ T ~ T~ CERT Np
3 Sntombmen 2. 8-1 e o ~ ~ : 9
57fEElA00NE55 ~ OR?AIOSTAtE
t/vET~ ~tuE Pho@ni~e, ftAIIEwAt- CTORorpragl.erfpa. TUfiEt l~AT ND
y"~ 3 Grimshaur- Bethany Chapel, 710 Q. Bethany He Rd. r ~ ~
t0 THE EIiT os >rrr KIIOwlE00E. OEATN OCCYMEO AT TIt TrE. DATt: AID
lAEli EXA1111IATION AND/0,1 TqN, N Yl/ OrrAD11
L€p'~%l n > KACE ANO OtE~ C~E) iTA/T/~~`+/j ' pTMNM1E000I~M~D tD TIE TIME. DATE AID KALE AND 011E TO TIIE CAIREIi)
t'~!s ~ ~ 0 3Hb TT~ (/ujtq, N ' ~"~J ~ ~ T11LE ,
f ~ DATE SIDNEO Mb, D.If. Yfw, NOI1R OF OEATN ~ DATE SIGNED Mo. DAr. rnrl NGI1R OF OEA,N
~s ~ - / 3 - 7 -
~ Eo> u _ ~ 3:32 P H as a~
o r a NAME Cf ATTEI,OrIG PNY9ICIAN i OinEA flUV/ CERTIFIER ,Trq fx pfM) ~ PgglglAaCEp OEAD Ab . DM. rOifl PRGIIOUIaCE~ l.+EAD (?1ouf1
~ JO !]N 30 AT
~ry^ vAME AND ADDRESS Of ATY9GAN OR MEpCAI WIMrIER f+YOR ar ptwq -
k _ W. A. WAR?YER, M.D.- 1 W. Gle ale PHX, ~ 85021
- • E 1E0 FLE MO ffE4T11A1t _
~~4 t9~ - ~~~T~I 0?TENC1TYi5T11TEORfCE
c .~f
. 1 d > c A TE CAtAE cfar QE
F` N S~ O P IJ E w.~ A9Pt1O70-
-y
{ , S OuE TO. dI A6 A ~ NiEAVAL
::rte ~a=~~r~- Pm - 1-t ~ ~ ~1.} lEu O N Zv ~-1/ ,~c s eETweEN
C OIXf TO.OAA>EACONSEQiIBR.~E c ON~T
~ tJG G-E N c~ ~-l~-R c- l IU o ~ A-• GE~ATH
%=:?ART/,oTIfJ1•DNitP.JwTCaNDlnoIaANDio1161inliloNMENTALFACTOnallml..w~w.r1. i...f
r~'~i ppfAtl pMY00M /A~UTOyV~SY wASCASEIiFEMED(OMEDICKEx11MNE fy
q~. 17 ~d t
_•...a TN DATE Oi MD oAr N~A/tY AT wOllltl DEBCIIIrE NOw MJIAIY OOCUWED
AC~f Q bMAMIr S2 M (~SP.dF >N r ~l 54
~y ? ~a KACE OF N,AlfTY W Ifo.f.. Elfn1 Yrff11, 4dory..lhe. wlfE+lE IOCATEO'? STREET ADDRESS C,TV OR TOwN STATE
Y 1 f1If0ET!!t ~frbla fre t 9wECiY
Fa: ' S0 ? utfr~ O6 ~
f~.s,.
~ J St1PPE~191TA11Y HITRp
•+I ` 57
r:...
;K'~~
~ _ t
ti - - .
X19 QCT -4 ~I ~ 19
=4~
S~~E~C E
CQUNTY Ft~,i. • •
~r~~t~OpGT(ER POITRAS CERTIFIED COPY OF VITAL RECORD ~
'A~F } Ai>.-l i:'RCENt CIRCUIT CQ _
'Aug 15 1979 _
epod.c tw. o/ M.e Ooc~+ncn eRC.aflt..eQ: steed rw pnc.d x eie se the YITaI REGGP-05 SFGTtOfM. OEVAR7~fENT QF ~ .
Usuee unCer the .~fnxaT o! AA 5 35-3=t and or aueceron of - IEJta T?I „'frjvlGE~S. MfOEN'7E~A>~;
;,r.-•. - .
t1 -
+`a~, ~ ~
- - 3 81 ? 0 ~ Gy r Sw~ef Nrys',fr ~ war a~•
of+'~•~:x -.r.~fr ieN'ty fef W N..HI Sr~v.c s. ,r ~ V
TNf coOY not r=fd /Miffs Mf'O.ted QA ..f.f) pp.r yfpypf., ftf. feN N cab. fnA M1ty~....d ..MA •i1y.d ieM Of AtfNn