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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