HomeMy WebLinkAbout1150 . a.-
t
49910 ~ ~
NlW 7tHSIYSIAIE hll'AHIMiNI UI IIlAl111 ~
CERTI~ 1TE OF DEATH
>a
?LACE 1. NMIE OF DECEASED _ fFhE! W/dA?1 /Llti TE OF DEATH .
' _ Gertru_ de _ I•iAYEiAM Feb. 16 -179 -
_ _ _ _ _ 3a. PLACE OF DEATH ICrty a Townl J T'l+ County la- Rtwlw+ae tNo and St) . _ lb City ar Tnwn
~L~ tit •,f ~_t` , L ~ L fly. I~, ,.ln. , _
RESIDENCE ax 1 t r..V i 1 ~ { 7 j ~ ti
Sa. Name of ffosptal a Institution 111 rot mtMr, >F•• No. and St.l - - 4c. County ; 4A. State ~ d<. t•s4e Qty L.n•,n
I1 f
• i I ~ai~l'11 t", ( left 11j~r1~ (•j ,a (t t~ ~jC'`lal~'r,_•jF ( - ~1.1 Ves ~f~to -
ct- -
' S0. If HospW w Institution, EJteck oorrat bo: Q EEariT•I Stall Ts. Was Deaeted Geer in U.S. Military 7h. War 7c Dste
~ O DOA ~Q Irtpatrent • 2 ? EEarriW 1 D Widowed M "Yet' t111M and Dates From
~ O Emergency ? Dieter: _ 1 O Sigh 2 ? StpvatEd 4 Oivoroed "O Yp No To:
HDS?nAL ~ S///$•~.ea ~ • 9. Date of firth 10 Age Lot Brthday l la. lkder " "Year 11D Unen ''1 Dav
' ~ ~ ~ i Ll ~ MONTHS ~ OA`/S - uR5 M'NIITES
T__... _-___-1_ _--__-T-_-___
F - - - - _ _ ' t?a. &rrnplap Iiute or Foret9rt Cotrsiryl 1?b. CtrrEer: 01 what Country M ll Surrn.rtg Spwu 111 Wife, fJladm Namet 11. Socul Sec~~r}ity Nurnbwp
'wGE I ~ LIL•tr~r: !11 1~(_~ ~ l•. 1~ F1.{~. j").?r }fit\.~~ 5R'r l -1t^6L
r15. Rap 16. E tonic Or.q~n [ l Mea,can Ir. Ott+n (SfxufYf 17. Name aril A+fdresti of t sst F mpluyer 1
C 1 /liner rcan Induln tt
R ;S vn~te n other lspee•ly) i "Pr,c.to Rtcart nalyn ~ I~ (+ly {
! ' 7 Bixk ) G,by, ^ cxn.w± jl , 1i. 1 r'1:.1
I11RT/1?IJ1CE 18. Usual Oacuttai~ort IKtnd of work done most of r 19 Y,,nd of Busrtets w lrtdustry I
Ltfe ~ Mn it fetred) a~ t '
~ f ~r~l, a,l I{ . {1 Cif 11_ 1 \ ~l IL1/~1(•t t
i -j _ _ _ _ _ _
RACE ?D. NAME OF FATHER (Frtt lM;ddlel Ilastl ' 41. MAIDEN NAME OF A10THER IF.ntt t!U:ddlet Ilastl
rc Rs~
~ I~lilr1e~r~ ~`\Itlf. r~ ~ t/ll I~.rsr.L•`~---
- - ' - - - - 21b Relat+onshr 21c. Numbs and Street ?td. GtY or Town ??le. Sute~
. ETHNIC • ?la. /lame of lntorrttant G i ~ I w..
i _ _ ~ / V
~hrS 1 rl;l: lr! (l~f_r-\11 t^ ~ni.'Ca%~~r~ ! (^1.r15/.e, (VII. I~illt_IT1r~ ~ t ~
f - - " - - - - ~ ~ - 72e C.ty w Town - - -~??d. Sure
GAt7SE ??a Dnpot.twn rr Rerrwral T??b. Nsme of fimetaY a Gernaray ~ - fjf
" : B,r •a! ' .Other : ~ ~ • r , i j t . 1 w~ / ~ c • ~ `r . ~ P r l' i 1 ; • { \j _
i ~ LL r- 1 \t t r (ills ~ ~ ~ 1 -
l Cremat~ort _ _
MACE OF - - - ~ 23a Name and Address of Furxral Horne - - - - - S'gnattre of Furtpal D,actor _ - - - - ?3c N J. L~oense No.
~ ACCIDENT w ~ J Vl r ' •n? f ~ ~ ~ ~ 1
I I ~~~Irv~j •~i Sc~lt~tt _t ~~ka~fie_~cn_l.~t_~•- tt '-1-_'
o C (Q ~ l r 1 1 N S 1 i 21a. Signature of Req~stra* / ~ - ~ ~ ?l D. Date recur by ~ -
N ~ / 7 Re Wiry
~~tJ?>x i ; t~r`ln~. E. N j l " O~a L`~ _!~•ll.._~-. _ G~?--~ ~,?~ia2! _
YSa. Nor d Adbr N CerWYr- Atwdy Fktra O foal E+aR O Othv ?5b. to rna Oat o t dears ae i3na_ dare anc v4c.. dw u.xts anted
~ ~ rt ~ G {1 t r d ~ • ~O h s i ~ ~ n ~y/ ~ S.arw.re ~ ?.l, . =Lt~.'= •~X~Ct ='i
` ~/G I V • S. ~}w ~ 06 Scct / ~i zk. oats ?5a ito:,, o+ ?~t. Pro:b,.,;t„~
D_caa _
~ ~ / / ' Death t w~uw ~ ; ~ oil ~ /f ~
-
_ _ _ _ _ _ - i ?7a PART 1 In~ntedute ~ IEnter on9/.on•ptr~ ~ 1or (bl, and Icl. Inte*rat txtnreen Dour y_ M death'
~ ~ Due to or as a rnnseVtxnoe of ` _ ,
` s~ ~4 t ~
- b- _ -i---
~ • Due to o• as a constquenp of . ' ` ~,L:
~i',.,tU.', ~
- ` I~f ~ - - - -
~ -PART 11 Other s~grtiftcant cortdtttons - r 'yPlatad to wx n PART 1 - 28. Wet Autopsy I ?9. LVas case referred to Med.W
a ! ~ =
~ ~ y . • ~j ~ ~ . ~ ~?hNmed7 E.am,ner a Cororte. r
I .r )'~a " ~ E~; 4'Ya D Ho~ _ Yet
30 :)cats due ro Hom.rde ~ 31b Datr of tatwy ~ 3tc. Hour of Inprrtr
Aeeafent ' t Under lrwestgatroct ~~ig~~ p~ ~ri~ G VVS•: _ _ - - - - - - - - - -
' ,p `I ~ 31d Mpry aT Work 1 31e. Plop o} Inwry ~ , : ~ &tildrg ~ 31f locat,on (Ho. and St.l, r 31g GtY or Town ~ 31 h_ State
~ 1 i Yes O No ' C1 Home Street ~ `E3 Dther
Farm - f...rn.v 1 _ - - ~ - - - - -
~ F~eo.~• l.= . ~IIEo
8~.LUCIE "lA.
~ CIEF• 'kt
~ RECOH-
DEC I9 Z S1 PM '~9
. 469910
l
nR n77 ~ ~ I n