HomeMy WebLinkAbout0452 • 4'030
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OHIO DEPARTMENT OF HEALTH
7 NOT
~{iTE INMApGIN No D DIVISION OF VITAL STATISTICS sIN.FwNo.
SERVEDfOR
~rtDATACOOIND IrisaryR.SOnLNO.~ C CERTIFICATE OF DEATH Rgblrar'.NO.
1
1
~ DECEDENT-NAME FMn 1fMJY Lett SEX DATE OF DEATH (!/a, pr, Year)
` - John M. Trent !tale 12/2/78
' RACE-N-S.,ri1wu.Matt,ilnwt AGE-Lat BrtM¦y UNDER 1 YEAR UNDER 1 OAY GATE OF GIRTH fro-.Qry.Y..l COUNTY OF DEATH
can I,dwe, eK.l 6SI¦¦+11I IYranl Moa. 1 Dav¦ Nowt 1 Yw¦.
' ??hite 48 I s<. 1 e- 12/26/29 ,a Trumbull
- CITY, V ILLAGE OR LOCATION OF DEATH HOSPITAL OR OTHER INSTITUTION-Has. /lJwr r Nr4r, etr teerrrW +nrMU IF HOSP. OR INST. IeldcW DOA,
- ~ Yuungstown Tr forth Side liospital ~/~np:il~i n/~"
STATE OF 61RTH /gwer b Lr.SA., wart CITIZEN OF WHAT COUNTRY ORIGIN OR DESCENT IIIYian, W¦:pI1, t'rrsael, Ew,MM, Ce<ea,e, SOCIAL SECURITY NUMBER
1 1 twwall ! ?,eaeao Riea,e, ale.! (SIrrVYI -
1 enna. USA Austrian -Etl dish ,D- 17U-2::-5358
_;:c,~RESIDENCE WASOECEASEDEVERMU-S.ARMEOiORCEST MARRIED, NEVERMARRIEO, SURVIVING SPOUSE(!/.yr,SM1rwlYrw.wr/
~='E DECEASED !Yt no.waawew+e (!/Trs, Meta stnlee/ NIIDOWEO, DIVORCED /S/reyT/
iF DEATH „ayes ~//11/51 to 7~11~~5 a•larri ed Uonna 1.1. icasey
r~gED IN
•.>r,ruTCON.GIVE USUALOCCIXATION/Ghrttweet.rwtder,tr.rSsoero/.warrM/r.trr+1/nrlred/ KINOOFIUSINESSORINDUSTRY
_'-J`.JN 9EFORE IA pelf-L:mployed 14 1`ire ~3c Alaignment Co.
n'cS:LEi.CF-a,:.: c ,;w:iTY I.:i:
i, :7iiLAGE w'i L'JCFT:vJ~ ST,7EET AFi'v tiiiU6'cR ii.'S:DE CITY Liil1T5
/SIrN Yrt w No/
,w i'a. ;fercer ,k. Sharpsville - ,b 924 Mayfield kd. ,M ~es
FATHER-NAME F(rtt 1lr1d4 <aN MOTHER-WIDEN NAME Flee Xp04 Ar»
Is Steve Skuba la Uorthy 'Fait
NFORMANT-NAME /Tl1e w Auer! MAILING ADDRESS (STREET OR R.F.O. No.l (CITY OR TOWNI ISTATEI 12111 ~
IT. Lonna ~1. Trent I>n 924 Playfield kd.,Sharpsville,i'a. 16150 f
TART 1. DEATH WAS CAUSED BY: (ENTER ONLY ONE CAUSE PER LIME fOR /t+l, Ibl, AND kQ BETWEEN ONSET ANO DEATH ~ ,
11 l ~ , / ~ `
IMMEDIATE CAUSE 1aI l~~~71 [L~ .(-.F'GC l~ L C'~{CL~
I OUE TO, OR AS A CONSEOU NCE OF:J ~1 '
- - cewe(ae,t.tf~n..Aldl 141 /jGCL~Cc LC(~ ?'lls !rllC~C= ~[L.Ccc -
rut to wutnllrrr .
rNUt, altt6eZ rAe ewiter• ~ DUE TO.OR AS A CONSSEOIy/E~eC OF: ~/fJ` ~
' 1 //i[tawtlnt kl ~El~~-~• ~~LL ~ (lL.C'tCZC4 ~ , it 1, ! L 1L~
I TART II. OTHER SIGNIFICANT CONDITIONS: Cowdltloea trwaYraq ro lrrM.rtwor.rYree to rartr eleee /+hrr/Irl ~ AUTOPSY WAS CASE REFERRED TO CORONER
/Yra w wo) (Sler(Jr Yrt w Yo/
19a. 194.
- ACC.. SUICIDE, HOM.,UNDET„ DATE OF INJURY HOUR HOW INJURY OCCURRED /£¦rrr arlurr of M/r4 tw lr,r/whirl/(rn. 11/
- OR PENDING INVEST. (SI¦'rUll Wo+ra, pr. Year/
- 70.. 704. ZOc. M 7QI.
INAIRY AT WORK PLACE OF INAIRY Ar Aonr, /epee, tart[ Jarrory, oJ)Irr LOCATION (Sorer wR.F.Q wn, tIry w trsrr. ty/
' _ tSKrtll lea w wol ?tJe-. etc ISIrr(la/
2M. i 701. Za
_ To w corllpLCf?d by ATTENDING PHYSICIAN OdT To b. Canpbud by copONER ode
71a. To IN Oast of my a^o~~M~n omma al IM Ireea, Wta aM pea aed aw b rM oust!!! 7?a On tl,a Oath of e¦as+ruon andloe imaalpn~on, .n ntr opw,Wle ara14 oeNrr¦d w W tine, dau
_ s[sa0. ~ 7 • ~ / .n0 pac. and dw :o [M cauwlll /utad.
_ Is~r..~....e nor/ • i:r:G ~ l~ rst~.,.~. w oar/
DATE SIGNED lara. Dr rir _ HOUR OF DEATH GATE SIGNED /Jla, Orr. Ywi IipUR OF DEATH
214. ~ • ~71 M 774. 7h. M
PRONOUNCED DEAD /J/o., O'al. Yta) ?RONOVNCEO DEAD /Horn)
. 77d. ON 2h. AT M
NAME AND ADDRESS OF CERTIFIER lPHYSiC1AN OR CORONERI /T)Kw Mwr/ ISnrrrw R.F.Q Nrlw.t9re. nra, ry)
BUPIAL. C(iEMATION, DATE • NAME OF CEMETERY Oil CREMATORY LOCATION (CT , +RMK, w remull ISrtrJ
OTHER /S,ert/y/
,wHurial 7.4- 12/4 8 Nest Side Cem. ~7~' Sharpr~ville,Mercer Co.,Pa.
NAME OF EM6ALVER 1LIC. No.l F IRECT S SIGN R ILK. Not
.1 i n. Alexander tae Donaldson 9475 S)47S
FUNERAL FIRM AND wDDRESS /STREET NO.1 (CITr) ISTATEI QIPI
77 Uon~cldson to n 'u era! lfoel_.: 1'l4'Main St.,Sharpsville iJa. 16150
z ATE RECD 8Y REGISTRAR SI IOATE PE 1SfUE0 SIGNATURE OF ?ERSON ISSUING ?ERYIT p~
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OCAL REG ~ ~ /1 ~7 v t[„
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~ 19c0 FFB 25 ~ ?
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IUCIE CCSiriTY.FIIA.
ROGER POITRAS -
CLERK CIRCUIT COURT
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