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0276
l - - ~ QH10 DEPARTMENT OF HEALTH- - ` 1 • i / DIVISION OF VITAL STATISTICS i~.E+~~ ~~~~L~~ I y - - ! Rp Tlyf Nn _ _ _ ~f_-.r- r•,~ l~ ~ 1 . '~,..,,r<,:..•... CERTIFICATE OF DCATH - I I•frkLE:r' '.:.•Jt t.ar ?!:.tl:e Lsrr (${:t DAtI GF :ATRtIIa. Pq. )r:•. a _ _ u r~~~~ _SP•~:_TH, `llc':~1~ ---'-'~c enil~er_?~~1`,~7~ - F.; ~ t ~ - :,t, Ef.•t.. yr + 1~.')FR 1 rf AR t. •.GFR 1 fla+ yUATE (1F 6 1*H f:_. t ~L: f. T\ (~t O[AIN tl t' U2~ 6 j _ ;rr~L'C 191J . rU~/ifhCJ~~.i • J. Ir,. .1 :.T t- aI UH UINFH..,T (TUT J •.p..,.. , , e. re.r v:rrr-^ ..a rp D : • , - on floor in re~iroom, •ii \Ierricl: Chevrolet E . , BcrC:~---- - - - - - _.(:Q1liP:?n1`. 1'1'Q~lt fit r~tE:t _ - - _ d.f 1s' Ile r.:.r-e r a a .._~s G'ICeN JE .\.1 :.i ~O~arRY S'1 - 1 •ii . , a.,. t.•:. , Cny:Y+. ~~'.a,- 40CtAC SE CUgt't M:vb. . - , i _ ~ ~ ~ . - r - _ =t- -s-- r:r" ;F-=",. •)!i :,ui~A•ivF=.. CHCEST ~t•ANNreO.lFVfrli•aRHtED. j.'!F{•.tvl`:u S76.;;t ;11 .t'•r roaylrh n.:,.r, t r. t. :csalhs••.er .rl, (t•r ditrr ~f unttH 'tYWUW iU ...HOED ,Syrc.b _ C: ~i ri>~ 1 _ _ 7f IIS.1 E 1-. _ it :I;•- t: is i:.. I ....4 ;;_-l'tIDA'~(~:., ..=A.:.1 iCn.ua.rn~=n~at of •..;•f.ej LJr. nrn tJ t TIC.•Q F LvS~r,CSS U:+77. Ja. STRv - ~ i?~•rrick Ch(~vrol(~t, 'n-. - C: ,n•Y IT• ++ua,t _11 :7 a•fo'+ - I / ~r; ~hnE;-i B3`~' `!1~ IiIQ(' ie•~i~h 1 .l• ~ E~LrlcStt I'f1e it _ - - l - t•rV•J:: '1.C La;~THER- A!a .it'. t rr 4t:. ( - 4 ~ r ~,f~~: ~ J(^ l Lfl ~tG it lri i3_ r + Vat. V,t, a;:;,HEcS .>Te•FE T t r U., TO.\•.' :S:. TF+ ~ tll ?Ff_^~ ~ (b_'ct ~f1.~}t E%rj EJ111E3(;E:, ~1~"tli+ .'r'. • '~"ATHYJAS(CAUSED-iSY,{£~JTfRCf_CYC:'."C~ '.£_EI7Ut:~C'I;.r 'w, •''~+--j------ I eiinEt~c~. _ . ~ , 1 ~ ~r-•:,(utaT( cause Pi'o1~ab1~ h)TC-~C11~lYi' ~'~r(1soYZ1~C~~r_S11~C1~~.-- - - -1- - ` ~ •••1. . ~ - --J..l ..f.. J. ~ •.e i.Jr_th ._t~l i.. i~:r q:•m t, t.Il - • -N \ •I. ]"s I.A E R. t:H+. ..F - ."n};Y.:f1 trr _ ll ~ r - - ~ - ~ .r DES - _ G - - _ 'H.;LH E.w IY..JHr ''•EU •.rt ,ryrle i?: IL 1. i ~ _ i ~ ' i 1 ,r.. _ i f , F - _ T . c. 1r ATTENDING PHYSICIAN (:rly T , t,c Co~+pt-ra ]trr CUPO`~ER Gnty ,y U~... t.. -~jI/ C/~/!~" r.o r4~ yea - . r=. ..,.iy. ...e t.-•..~s••.~~Ni[r ent c,e ^.._r~{:._ r-. - e a - ' - .'t 1_~~~('I~~~~E=-Z ~i), 1~~E1717. AT .);4E1 r`t-.~ , . _ c . . _ _ iR CO9:..' H.:1 rY.:,r. r X }-Y 'r. ...fir.::,.. 7r f 1i GF3rlx~r '.I,n Coroner 21 21 ••rf_r~_j~i ~ F c; ~ t vr'l~er-,~. , Ghio !il:1 ~r . - - _ _ • • it :F 1t%iY C:FI • _ 1 ~ - _ 1 ' -1 _ /C~ -''---i "J ::E'vJE3ad ~':1I1" 1 f°.E J` 4`t, _ jtE~;•F~ ~tI=?E:, f; . i .tr ! I...c~:-. c 'E. _ J. ~uE:' .~t-J X81 _'6 .^_s - ' 1- . ~ •i ~ _ _.__IS7HFFTIu U... v._-S~IA:FI 7~.: J`\ - 3 E_• ~iD~F._: If]C 1~~~~ LIF ;SC'1T, h'Jf' l iiL•:!~~.t:, .;f110 ti~ 1f > 1^ OBr r'1. .~:{+iRS $1-ytiATVRE .~fE ~thYET ISSUED S+•..'vA Etl'yF "'F ~[NS~If ~S$ulaG ~E F+?flr . c' C~ ~f 1Q