HomeMy WebLinkAbout1930 • ;
• 4'72313
~ ~ ~
/ • : ] C[~r~NIYIEtdf OF t'uG~lc: HEnITH i
CF - ~ y.I.a.. •~.•.1 - - - - -
Z ~ ~l STAI! EIIE NUMn_R 1
rci,T~?'ii SF_:T~~~~T:.i~ ii ~~'1•':1 _
OECEOENT NAME 111Si W'aK` a.\at ' FX DAII CI h! /UN 1.110, uly, Yi y
T _ /h._/~_-~_/~~ ?E~c3r i
t-it ~`'i-o-.~ t a:.~ 2:-,:.AL , ~ Vii- T. 17th n~;
- 1------ - -
R#CE-I•~ w._r. a,.... A4E-1..• Meh•., UA[?ER 1 YE/UT .INUERt-1 PAY p>TE OF BMiTH Ik..l-. Day Ti/ COUNTY OF [?CAlit
1•e• t hw«IA'/ lYis YOS T u•\S ~W\M:$ 1 Y••n `
_a. tEf.T;1'... 1 sa_- 1-S°--L--___-1.5: ----L_~6_/>,Ui,. __?~?~d_t_;'1:'17, ~'~AYC;_: -
LOCAIIUN IN [MA1H vt5•LE Gtr Iw is l:t - 111pSIMTAI OR OTHER I.VSTITUFI,^,N -?anr v•w..•.•:^.+ ,I..ru:.w.+r.••.•ar/+
' :
e
~jw t~.Is.,t Yalu a.,ris«C~ARDr.N CITY ~ GARs7~1 CITY OaTIs(~PATiiIC 'tiOCFITr+.L
~ uCnN JF \~+ut Cout+IRY vew4
~It.Yr r.+_Iia1a gURyryM:G SPOUSE /Nwrh, gnemadrn narneJ M4S Ci IMNi k\tR M (i
Sl~ry M iM:11 r...v V S A '
WralUA~D. pn.(A'tU J..n•AI US ~ l1aYD /OMIt SI
•t~nl T
OC^"II•UW _ l•~T~ill lStl,1` ~y `~tiJ• • 1O. Ij\~ • •i
:Aa.vw A.•/
M a'.R7N ~ • . A I:~~P"~_~;0 t,. Jf>,ilty F. K(~'LLO:•1SIiI T2 ;;0
- - - - - -_.a
WailT t••/j
4t .I~y,,y Sf.u..t, as t:ulal\ r.:a/stbER USUAL 0a't.u:'AtlOh l.+.a /w~J IJ avorA dwle 0uru.g m.76r [Y IuNU OF t]USINESS l/R tivL: S1NY
11n~_nhr, a en d rctued
tr,..•ttt..~1~•. ,3.371-('a-02'± 7_ _ T.a RrSID~'~'_ _1?.,~ Ac P::: HUD
elslo:wct tlavs - ----f---- - ~ •LT..~r.:{ ub. -
CUlail[Nl RESIUttKY-SLATE -'CthINTY IOa:AIItY tt~,r•t~• ulr~tur/tsor STREET ANO N[q.SRER
~J,.i[~~t?E \ra•AC[ arrliS;,~F''AR}30Rr 71j10 ESPY iL'Tl7 e 1
LIICHIGAN ?IAYh';
l Sa. 150. t Se. ? a 15a
FATNfR~ I:AME iri~i ttiDOaE tA': MOTHER-MAIPCN NAME tWST w1K+at aa3T
--;'`i• • ' 16 nAl':I1L J. GO'',IEA 4DAH F:0!:1Rs
WFURAUINT rNUUIatG Af>DRESS Sillltt OI\ at a AD ItiTY Cat tarw• sT•TE TIP
cola,nlDr•S ' ,t,1 F CC"l T' 741 p ^r•T? ~'!',l7 D::=_R30RP' t'.,,-..a-:~'F',;' _
e awv 1 Sa IS:ynaturN ~ a " Ji f \ • 7 1 I u11 1 QF ~ • ~ • 1 j t-a(. rte.
NhCH GAr1 - t•••..M •e1~ee'• a•Mt •lIe O•.In
a,y tD 19. IMMFOtAFE CAUSE /fyIFROKIYOIIf CAUSt FIER /tNf fUR;a/, /DJ. Ak0 /cl.!
11?pti tvrlR PART 1 ` 1
u1a1 (al IJ /L~•~ i~/r~~- _1~/f.'t~ tt-4hVN ( i E•f ~ ~
STAi.\rti TNt - _ - -
'?ai-~•rne DUf TO. OE• AS A CONCEOLIEHCE OF. ~ 1 •ien• c.t..•1. a••a W e<.•^
uv;t t•St ~ .
~ _ ~a~~~ c•._}mac e~..~~...,.~-_o ~ a - ~ r Y~~-r
Ib~ -1
OUE TO. OR AS A CUNSEOt1E1:CE (>f 1 rr.•.y Ml.vr•• •lnet w
"'~r~" ~ I
~L ltl - - - - - ~ -
- PART 11 UTHfR :•GH~ICAYT COFiJITNi•J$-te..~•:o-s rn•re.Ina a e.au.I...w wwra to cwa• s+r w vwaa 1 ` AL'7gF'SY /S!w•tly Yes `Y.'AS CASs VEFcP+~E7 lU b~ECNC~-
. • w A;nJ i EX0.MWE!i! rti•:e: I.•r Yes or Jk1 I
PJ1Cf OF GEAT;• /z..; Iw.•--- F HG>r- OF+ ;NS!.• 24_ ~ `
1030.v •+/IJ.</--:/J~~ICy1 y O•. tl.•w b••/ I••yata'1 iSi1PC`IIt ! ~ T.S e•u .ew••C .•N•s.tfI.N! •Yt b u i •••e04~ c.w
ri- J I~ • ' 22b 1.~a J l ~ t ~ ~7 M A~ NN : 1 I.M NIJI •-CM aiti M•~.tVr~ I. n•~ JL'• M /<N'• A-•~10 •1 W •
• 23a. IJ Ivvru tI I..• app 4i(.• j// 1 ~ Iwt..'.It rJ! F1:• c ti" • • i ' L:. hi I _N i:i V+. W v~ ((~x.a. 6taa
? z /Srgrwtwe acrd J:r e! ~ ~ n ~ 1I ~ J ` * Si9nature_end lnk! ~
DATE SIoN[O fMo. O.Ey; Yr/ HOUR OF DEATH t 2 ,eTC SIGttED i/•b.. Jar ri.J /FOUR OF DEAT?1
r u_
c> 270 ~ _ l_r - _7 ~f ~23c SJ ~7 M y< 2sE'- _ ,94c - M
C
- ` - V~ NA1tE OF AT7ENDIt:G F'NYStC1AN IF OTHFH TH4N CERTIFIER /Iy,.edAntJ ~ PNp1i0UNCE0 DEM /AtD. Day, Yi/ I
f•RUYJI:hCE[? DEAD (tcrirl
13d. _ 74d ^N t'•ae !:T N
NAME ANU ADDRESS OF CERTIFIER ;P/,.stu•. Oa Vtu<AI Eiwv`.ler (Type x AenU / _ _
_ t5. 1 • r ~ L=t<~~L' ~ V it .1' J ' ~f_ sv ~!S i
E~~ i t - c r
A_C. S:¦ce~a Ito+.•, w:.:nu
(WTE GF INJUNY /Mo, Day, Yr.TNOIIR Of INJUNIF-~-SCRtBE HOYf WJ:/F:Y OCCURRED
~ ol\ nl~lw, rrltsl ~r•,. J.~ f
~ 26a 26b ~ 26c ~ 26d
NJVRY AT YlOP.li PLACE Of INJURY- As I.am• tr+• •.er. •sna r. e!!Ya ~ l0
~ATIGN SiRiEt O!t P E D M OT/. vtlnfi Oa '~1M1 1+S•••? SrA~E
/SpecIJY Yrs a tSll o..+a.•e .IC /SJlecr/y/
76e ~26f .260
BUP.IAa, CitEMAt16N. RfrriOVA1. OTHLH jCiMETERY OR CREMATORY-NAME ~IOCAItON ~ att. VlatsGt. an To'r.-.51•.~ STarE
6 ~ t r:wr•c/yl
i~T- T t r~ r
j f;R'~-~":~;"~; 2Ja ,V `%.7._r.7/ - 21b (`_jjA -_,a._4 .t--~~ - - 27~~S.C.-t'~l~+•i..-1+-3 -f ~T-~~'1•
r.si._y~+'- DATE /I.fO., Day, Y/i./ ~ NAME OF fACIIIrY T ~F ADURE:,'S OF FACILITY
27d- ~/7f f i :~7Q I2 i,,,C1_i_:.`J ~U"'-'~7 ~.1: .1";" P~'1'~
- 28b 1- ~1 -.r :.~~i~'` ~ T,• - - T
B-36b FUNER:.Ef-•%RVf'E t'CCtiSEE 1- / REGISTRAR 'I ~TDATE R/Z~VEO 6Y~AiG~FR~R'//Ao.. Dap.
I ! ~ Yr.l
lS/yne! / ' /Sry'~a:unJ r ( _
(4 78! 29. f,• l~_ f/!!1 I ~ 19a O? .ate. J~ ~29b f'~
I~it~~-..- _ ~ .
I here~.yy certify that this is a true and exact • ~ _
Of a reob~zri a:1 file in
thle offices of the City ClerYT., Garden City, itii • ~ atfi~e9teci_ to by the
seal of the Gity of Garden City c-sir~ossed :~erea ~ ' ; _ - `
_
SFP _ 1979 ~~C':-~~. . • ~~i~ ,r~`~
Date Imnald D. a:~walter,lCity Clerk
4'72313
1960 JAN I I A!~ .I= I0
si
~t°~ci~co~iTTOYt[o~o~
ROGER P ITRA~
CLERK C[RCUIT CDURT
RECORD VERtFiE^
800 PIGE~~~