HomeMy WebLinkAbout0201 X63626 ~ ~ - ~ ~5"S
CERTIFTCAT£ OF DEATH Stats File Ns-
`:O. NL~Gtia Dist. 210. Custodian's Na
tfial) (l~:iddia) (Lsst) 2. D71TE (Month) (DaY) lr•.;1
L •=~c35~ p; r~ Try OF ytA
,s o: ?r.-!) ~`J:\iA S~1Ll:.~ ` DF'A~ 1'J1Y - IJ i97b
_ V' ~':.tT.}l (C01:atY) '---r _ 1i. U~J.iL H;.~IDENCE ('NTTh~t•ra deceased )itsd. It institution: reardrnce bdore admisaios)
~...t:li.a I Stats---- JF.D~~LatL_Count7f--~tjJH~QTY_
_ - C::7 or Io+ra - - - In City L'mits LENGTH OF I ul Lane LENGTH OF
Yea U No Q STAY (ia this place) Yes] No ? STAY (Vin-fthis pjat:e)
k~ a'JTA I 2 DAYS City o• A~Ba?~ _ ' 7 r :is.
Toar~ .
_ ~ sn+ us?• or iastitu!ion ~ LEf:GTH OF Street Address or A.F.D. ens Do: Ito.
5??7
U'+1PIr~S?T'f HOSPITAL _ 2 HAYS ' lp~~ LR.uErZIDGS DR?~~
~ ?..tOti.L 1 ~.A:na L...... (.~:+tc •.::ra:gn Guuclry) COUNTRY?F ~~T (S. )S R.':SSDENCE O;( PARb!? l6.
SURLLL DA
1 AEMOVAL ? v
. i Tr' ~CJ(:~ Ctis1TY, GA. i _l!. S. A. Yes p Na~j I cRE!y'aTI02t _p:.A 13, 297E
C; 31g-it i§. AGE (:a yaars) IF UNDEt1) YE.t2 IF U:iD:.Ft 24 HHS. N1ME OF CEBL-:TEAY LOCATION {Ci!Y or 7es?a) (County) (Stsle)
1,~_~ 'Mant4ti Daia Hours II Min.
_ ~3' ~ 1t? I 1 "°t^?y^' HILL I ALT3~.'!`f iJC'Cv~FR'tYriS?~IA •
~ '`ct;::8 :'.iiit3li..~ tl+:ri~~ or Widoti?ed Gi?e Nacre o! Syouse l7. E.titijALMER'S SIG?(ATUR.-: L1CE.tiSE HO.
: CO"J~D~ ~ D'Y03CED Q • y`V `~t
sE'_~AIEa7? ~ i.^~~?CJ.a ~?:=J 4l/~ ~l/_r.rf_.~"+~C'---- ~ O. '77
ni. v~vii?AT:O:( (~+ive hind wo:;r :a::i.'. :~(::+ui:~.i .^.3 13.:~:..I~ ,.'.2I
~•s j~ri:q •-ast o! woriiaq lire. e>.en i! retirsd)'L`Ii)i:S:RY
L _
C:~::3ED LvER IN J. S. AR.yIED FORCES? i50CIAL SEC'1RITY NO. i9. D:J:.:.L=._^e S ia~_•3asJ -
iY': K~, or uaicaou+a' (1! yes. gitre aa: or dalas of aereics)
. ~ ~ IA ^1512 ?503 ~3t;s~n R~, Atbanv, ~-3. 3_~D2 .
F',: .?'S N><.*~IE 23. INFO$INAP(T Relatioaabip .
~rs?_?_: AL X S?IR:~ _ ?•?S. '~'~'~SA T. S~I~~S Td?~'c
•?-F,L3'3 .~.:ti3v.: LI. LtiEOH.u.A.YI"S ADDAFSi
~ ~ r ~`IX^?l j 180u LAi~SRi!?r~ D~. , ALp~.)v~ ~l~n~
' ° O: Di<4TFi ~ .^.!er on1Y ono ce_s:~ r+r :..:a for (a_), (b), sad lc).] PLEASE YditiT 1rTEayAL BE;Y/EEti, DO tiOT WBITE LY T.'iIS SPACE
" : DZAiF't :'!AS CA(:3~D i3Y: - I -i _ ~ OYSET ARID DJII:i ;
i .,rv'.DIATE C3USE - - j 1
2. 4.
- :ions, is :n7, DUE TO (b) I I
:h ,ave r.~e to S. 6.
~v.. list. _ DUE 70 (c)_-__-_- a
:.'.3; O:uar siga:bcaat wa•vtioas cont:ibt.:mq to death 4•.t sot rela!ad to tae ta:y`.aa: diseaaa coadi::oa gr+ea ro Pas I (a) i 13. AU2C?SY?
_ Yes No O
.~:~Ea: PLnCE OF L'YJUHY (e.y.. is or snout --1;tjJRY OCCURiIED
. _ ~ hose, (a:a, is^_:o+y. s:: est. White at t?4iezlr h.reby certilT that I attenled t4s deceased Iro^+ _
_..-_.'~E o!?:ce b!dq.. eia? f No: Nhil• a! Work 19-_~__. to__ i~____, ihat 1 :asf ss•w th. deceased
C? i0'NY) (CJ•JYTY) (STA7Ei TIME (b:oatS) :Day) (Yea:) (Hour)--;
~ OF ~ e'.is oi__ I7__ and 14a'
i
_---t 1\J7RY dea•S e~cs^ed at___.___m., Iron the causes ani on thr late stst.3 aSoee.
~v-_ ~ r "c in~J ..If i,vR~ ( ~ DA:i SIC:tJ
g _~t
~ - t ~ ~r t l,~ .n 1
_ . _ Q C:'?' 1 j Ei2: C E .._~J i~ L~ 2t E:CC•'_ ;1% Ci)ir~.C COQ,, O CE'_: _ 2 i 2CJ _
".t i~ ~R I2~-<'. lII t~ltal :','Cft`::': l~?T".'2C'.z .'!~:)ib :AtiitC;rr ~f:tt?`L~r~ L:COi~~_.) i
t
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