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~ 2~ CERTIFICATE OF DEATH r 46.4.982 ~ '
l~ (n! Nwsf¦ i•tldNo. DeOORMM of P'.bYe ?1wN sr•n Nu Nww¦
DECEASED-NAJN[ nar rloou l•sr SEx OATS OE OEAM 1 rorrN, o•r, rt•s l
t ,
I. Bernice Y. Van ke , 2_2_7
RACE .mare, Nl6rw, •rtllC•N wpuN, AGE-ufr v.lot¦ r nu wlot¦ 1 o•r DATE Oi RIRiH 1 roNrw, oA•, COUNTtl OE OEAiII
r !K. I fletvr l 4¦raa•r r re•UI ros. O•y MOV¦f rw. 1
! W s. 50 ri Ta i i "T-1922 T¦ ,~layriC
CITY, TOViIN, OR IOCATWN OE OEATIt wfrDt em taarrs NOSMAL OR OITIER NSTITUrION- lu Nos IN lbws, orv! srMn Ar0 Nlrrses +
snun •ef a No
Dearborn Yes Oakwood iiosni tal
STATE OT RIRTM t N Nor w u.t N•re CITIZEN OE VVgAT COUNTtr MARRIED, NEVER MARRIED, SURVNRdG SIpUSE 1 a law, ogre r•IDeN N•Nt s
r cowm r WIDOWED, DIVORCEp l ssycr. r
I`i+ ~ T.ichi~an , U.S.A. I• fiat ed rI. A ex R V e
SOCUIt SECURITY NUMBER USUAI OCCU?ATgN 1 onlt ¦we w s+osa ooNt oll¦rNO •rpsr or KIND OF BUSINESS OR INDUSIRt
n wOUaq TIN, lrtN 4 ¦til¦~ f
Ir 3;`C)-i "5725 -I,. HOUSCW I'C ITi. HOICie
RESIDENCE-STArE COUNTY CIT1f, TOWN, OR 1OG110N rlfrs! cm la¦rtf STREET AND NUAfRER
rs!lcur ns a rro
Ita 1?ich. Iw '~a~rne Ilt. Dearborn I!i Yes Il..~ ;,Iavnewood Ct.
FATHER-NAME rear NroDl! t•f1 MOTHER-MAIDEN NAME rl¦fr rrarxt last
Is I~nacv Blaszkowski Ii Anna TokarsY.i
INTpRMANr-NAME MAIRJG ADDRESS Ifratr os ¦.r.o. No., cm Oa sorN, fs•n, irr
Ir. Alex R. Van D~rke In ~ ;iat~neWOOd Ct. Dearborn i•:ich. ~4r•1 24
?ART I- DEATH WAS CAUSED Rl': EN1ER l7NIT' ONE UUSE TER l1ME iOf (ol. (6~ AWO /r)) •rn u.u IN vl
ltrrHN ONft~/
4N0~Of•1N
li I+WOUn c•vu ~ i~~iG+ci
coromoNs, a •Nr yJ~L
rrNlcll D•vt use ro 101
Irreor•n c•vse Im, Dye ro, O¦ .f w cONuoueace or:
fGrINO 1Ne vwot¦.
IrIND C•Yf! Uft
Itl
BART R. OTHER ~Gtj?pC/u~T CONDITIONS: coNpD~y a~ rn¦ Np ro ~ w Nor ¦er•rto ro uvu emN w rut Ipf AUrOrSr ~ rES vre¦e rINO1Nos eoN-
J~ ,f,., /C I / / ~ r +ttf O¦ NOI slOlstD IN Derf¦.uNIM4 Uvf!
~c11~~~v'"//`~~ G / ~ f//mar- _ /"IA/'- I4 IsR - /
ACCIDENT, SUICIDE, ?IOAfKIDE, 1 ra, wr, re.es HOW INl(IR1f OCCURRED 1 tNn¦ wlrr¦e INwn IN /•rr r r•as N, mr sa r
OR VNOETERMRiED 1 srecln 1
~ ~ M. tY
INJURY AT WORK ?twCE Of IPUURY No..e, r.¦., srrses, r•cro¦r, IOCAl10N 1 anew W ¦.r.o. NO., an o¦ rorrrl, u•n r
r sncln ns a No / oNlct ¦loe , arc I sreclrr l
iRa ,i1 Iii.
CElTIEICATION- rorura o•r n.s rONM r rw •rrD usr sA. ar/ws carve oN ....,o/Dw wt ~nt~r sw pEATM otCUnEO •r sNe .uct. oN sw
iNT3KrwN: TO rONrN ra¦r r!u ¦OOr •rrE¦ 0!•ra. /IrQytl O•n, •NO, 10 ~ ¦!N
/ •snNOto tat ~ ~
Tll otG!•u0 Bor. 71t c or r• [NOr/t[OGf, ow
T4 7 ~ ~ t1/. 7L ~ ~ ro sae uuulsl sano.
CERTIfICATION-MED t ExAMI R OR CORONER- oN Mt ¦.us or Nou¦ or ot•nr rat oKeoeNr w•f r¦oNovNCeD ot.o
ti•rw•r10N d ar! ¦OOr •ND/O¦ rw wref/lp•npN, IN rr plwgw, a1DNllr _ O•r •t•¦ wOU¦
O!•M OCCYtltO ON rw D•n w0 OV! rp rw[ Uufl~sl fl•r!D
CERTIFIER- w ?uNr M. ~
S A ~w~~} d nsu DATE S1GNE 1 rN, wr, rwr
MAIMJG ADDRESS - CERTYIER I sutra o¦ ¦_r.o oa
WRIAI, CREMATION, REMOVwI CEMETERr OR CREMATORr AJNE l 110N cln D• towN u•n
+ steam r
Burial :!i r`t. Olivet :.r Detroit tfich.
DATE. rroNra, wr, rtA¦1 WNERAI NOME-NAME AND ADDRESS 1 ssuei o¦ s.r,e. NO., utr O¦ rorN sr•n, llrl
-T~-7 TT. Anthony :r~«oc?~c 12^ Dou all Detroit ?{ich.l~~'21
fIR! SIGNAis/RE J( T,A Af E Ars DAtE ED I;~ aEfsrSTtwR
~ ~'G'i'1. ~ ~~41/ .L.i'Y ~ K. rI ~ tti u lyl3
State oP Michigan) ,
County of Wayne ) ss. _ t
City of Dearborn ) ~ ~r
. : ~ 44982
I, John Jay Hubbard, City- _C~erk of the City of
Dearborn do hereby certiP~_.;1;E~~ this document is a tru~i9 ft~Jr'
copy oi' the original on file; in thi$ oFfice. '6 ~3 3' l;
a - .
Y,. FIL'tU ~hL~ H! ._'_i.vCi;
" ~ ~ ST.LItCir'_ CCj::NTY.fi A. `
- i ~ ROGEf2 POITFiA:i r
~y, ~ ' CLERt~ CLZCL'iT CG''=T
ate ' " i qty lark
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