HomeMy WebLinkAbout1614 ~ STATE OF MICHIGAN FOGS 02-23052481
~ r ~ '~n~~ DEPARTMENT OF PUBLIC4HEALTH
V 'a~~~O~ STATE FILE NUMBEII
0 0 1 2 0 8 8 `~=~;v'"' CERTIFICATE OF DEATH ~
DECEDENT NAME nwst twott ewsr SEX DATE OF DEATH /Ab, Day, Mr./
Ro F. Kendall s. Male j August 26, 1978
AACF-h,, wwr. twr. A.... AGE-e.n w.v+ep UNpEA , YEAR UNDER 1 DAY PATE OF BIRTH /ATa. 0a1. ri.l COUNTY OF DEATH
I lSiOK•hl I ~ DAYS Maws caws
s. ~8 s+. s~. s< BMa r . 15 , 1895 _ Calhoun
tAG1TK)N of DEATH ®,KSroe uTY eMwT: a Springf field ~~T~ ~ OTHER INSTITUTION-Mrw rr.v+«e,•.,.wr..«rv•.+.kcr
/Ctu'cA otle
.Id,pec~ ?..mtrwtwcEEIEMTSOr: ~ Provincial House
. . )D. ~ twt• a 7e
STATE Or WIM tee,r,eVSA g172EN Oi VRUT COUNTRY e+AAw~to. r:EYEw eaAwutD SUAVIVIYG SPOUSE /NwrAr. give maiden n,my was oECtotar t~tA r.
i DEAM err ewv.erp, W~OVNFD. ONO•CEO ISa••c~Ar US AwvtD rOA:ES~
o aWashington , U.S.A. ,oMarried ,8eulah I. Potter ;i~`°~~es
StE YAIe1,At SOCU?L SECURITY NUMBER USUAL OCCUPATION /Gwe trued O/ work done durwrg most Ol KIND OF BUSINESS OR WOUSTRY
wtaAwwq
3 73 - 28- 2 711 wwkiny wr°•'"`" r`t"`d/
~NCE~ITf'E~i6 Owner tae. Kendall HardHare Store
CURRENT RESIOENtI-STATE COUNTY LOCALITY eci+DE CrTY tMMrS Or STREET ANO NUMBER
Michigan Kalamazoo tii~ecsoEVatAGEtwrTSDT Augusta 15700 E. Augusta
,5a. ISp. tsc. or ,sa Drive
FATHER-NAME fIR1T e,ipptE LAST MOTHER-MAIDEN NAME rMSr YiOiD?E IAiT
,e. ohn C. ndall Cr stal Price
wF MAILING ADDRESS srwEET Ow wro MO aTY ow TpyN sTAIE tY
,BD,6108 N. 44th Street Augusta, MI. 49012
teest To IMMEDIATE CA (FNTFR OAK Y f CA PfR UAIf f /s1. /61. ARID !e1-/ wr wea.....n w ewa.
nrttoewtt ART 1
srA
ieo~Ter(*EO u) ~ A¢yyF ~ iC.t.s.T (~,i
c~E
tA~ST OUE TO. OR AS A QUENCE tom: - 1 ~y ~ ~„a wy
L.~ rol C~~
L pt_ 1 ~ ~•E-~Y
Ol?E TO OR AS A ODNSEOUE OF: 1 t••w~ w
• (q 1
• PART n OTHER SIGNIFIGINT CONDITIONS-l:oes•n.. ooMrirw, a saM, e.a .r rww es cwn• y,... w ?A11i r AUTOPSY /Speeiy YeS WAS CASE REFERRED TO MEDICAL
a AbJ EwwwER~ /speoh Yes a Ab/
20. No s,. No
PUKE OF DEATH poser. ?~w Mrw, F HOSP. OR WST.. e+a.c.n ooA 2aa. u.• ww.•~ w e.•....w a eo w . rwsy •cr..rrs u••
SveeiM v,t~ w.•. ew+o..r /Speriyl revere ~ .
a~~n Home ssbInpatient a<
DO.I Q 0• eM eras d .+s>•natce w~p mese'Y•eo.. w w OplO ,•re. seaerw N M•
23a. Ts M err w w essu w •e >tr e••r. ars w poste w ew ee ewr~ rse. w M•se a+a e~w w e.r cs~.risl srY
er u.sslr rsaa
, k b o Z ISggnaturc snd TitM/ ~ ~ ~:l~l
~ ~tY tij~2G~-- 1 ~1 6 !Signature an_d Title/
( 2 t GATT: ~SI/GNED /Ata, Day. Yr./ HOUR OF DEATH t z DAT[ SIGNED /Mo., Dsy, Yi.J ~ - _ -I :EpUR OF DEATH - - -
~p 0 ~ oZ- $ . 7 73
23b. sat. , 2:35 a ~ ° < zab tae- M
V ~ NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER /Type a Print/ ~ ~ PRONOUNCED DEAD /Ab.. Day, Yr.J PRONOUNCED DEAD /Hour/
2~- 21d. ON 2M. AT M
NAME AND ADDRESS OF CERi1FlER IrMYSeeeAN ow e•toKiu E>zAw•,'EIy /Type or ffentl
2s.Dr. D. B. Moir' on, M.D. 25 Crest Drive Battle Creek, MI.
ADC. stwaoE. Mora. rcA DATE OF INJURY /moo. Day Yi.J HOUR OF INJURY DESCRIBE HOW INJURY OCCURRED
oR ST ~ .M
26+ 26a 26d.
tiJURY AT WORK PLACE OF INJURY-ru nor. 4rnt wwt r+c+dr. sNO LOCATION SrwEEi Ow wro wD on. vr.eAet. Ow Terevrrsr.r sort
/Specify Yes a Abl s.+s.ti re /Specilyl
26e. 26t. 26g
BURIAL, CREMATK)N, REMOVAL. OTNFR (Sptrily) CEMETERY OR CREMATORY-NAME LOCATION orY. KEAGE Ow TDYYwyw? STATE
2),Burial 2)D Oak Hill Cemetery s,t Battle Creek, MI.
DATE /Ab_, Day, Yr./ NAME OF FACILITY ADDRESS OF FACILITY
2)d. August 29, 1978 Arley Funeral Home, Inc 28.05 Capital Battle Creek, MI.
FUNERAL SERVILE LICENSEE REGISTRAR
8 781 28c ~ ,e a /SignatNe/ , ~ DATE RECEIVED REGIS PAR (Mo. Day,
fSi nature p.ri/ 29s ~ r ~ ~~~~29b. ~
n -
STATE of MICHIGAI+i) ~",9 C~ ~ i ~ P~' 3~ 57
42.60'7 F
SS SLLL'C'i ~"li`lTI:F:;,-
RLGEft f'QITF:,v
COUNTY OF CALHOUN) CLEt~K C;n^;GIT CCU^T
I, Marcus J. Gray, Clerk, of the Coriiti£~i`~=bf . _ . _
Calhoun do hereby certify that the foregoing is a true and
correct copy of the original thereof on file in said county.
• Signed and sealed at Marshhll, Michigan
this_1!~_day of 1978
MARCUS J~ GR,AY, COU CLERK
e ~
. , ' , .1~~-~~/_r/?~r~/l'J/f Deputy Clerk
- ,
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