HomeMy WebLinkAbout1664 •
• :
f
t
- d° ~ 3 0 3 .
• ~ 4y / ~t..
X46'7 ~
481468
~,~.v.~H.an ~~Q~ DIVISION GF VITAL STATISTICS
N». Owt. hs. SeM. Fw No,, ~ ~-~1-----
,;~ti ~aracoolNC i,r,~,IRq.Do,.No. _ .~~12~--- CERT~FiCATE OF DEATH R•~•~•: ~ _ ~ -
• •JECEDENT-NAME iv ~ MY/k I.arr _ SE11 ' i)A7E OF [ _
BERNICE ADELINE rOLtL ,Female „a chi.
RACE-N p.,W,wta,B4N,Arralri• AGE-Lana BirtbAM UNDER i YEAR UNDER) DAY DATE OF BIRTH /JIe.,Dsr.Yr./ COUNTY Of f -
ean ioo•sn. ate-1 tdvei/iI f/Y[aq/ Mos. t Da[s Howe i Mrq-~ ~ ` -
a. i•~llte 15a. V t5a '5e. ~65AI'(:i: I J i ~VUb a~ T' - .
• CITY, VILLAGE OR LOCATION OF DEATH - •IIOSi1TAL OR OTHER INSTITUTION-Nato. (/Jaar tw ei,Ae[, a/nt sheer W arwaeU - IFd :.Inonv uDA, •
' ,e- Canton f,~. Aultman Hospital er. `Rr.
STATE OF GIRTH //J.orw V.iw~ arw[ CITIZEN OF WHAT COUNTRY ORIGIN OA DESCENT Ilta::an, Maaiun, Gstirrl, EnyiM. C~wlti ;SOCIAL SECURITY h1WiER
.
~ , . eerwlryl Ilntq Riea11, ase.1 /dI•N1rl
Ohio U.S.A. 's- American I:o. 29?-42-l~427
•~E S~~e'.CE WAS DECEASED EVER IN US. ARMED FORCE57 ,MARRIED, NEVER MARRIED, SURVIVING SiOUSEf1/W,d•t ~rl[+.+"[/
. ~ -F45E0. /Yet aio, ar w?s»rw/ I/17'ri.fr•s Aao y+[nic[/ !WIDOWED, DIVORCED ISiecl/rl ~
:vo. i•:arried I,A. Paul ~ . 'r'oltz
y , USUAL OCCUiA710N /C/•• aw.s y rent a,av ~w,f .,est y w~t•4t r7/4 [•ew 1/•[aN•dl ' KIND OF BUSINESS OA INDUSTRY -
GtYE
AESIOENCE~STATE COUNTY jCITY, VILLAGE OR LOCATION (STREET ANO NUMBER ~~•~"%=C•Tr ~'~•i°
O'rio ~,b Stark !,kNort'r. Canton 2l~1 Cordelia St. S.,•!~. Yep
- FATHER-NAME il.rf /IId/fe Lasr jMDTHER-MAIDEN NAME FM lfiddtr La,t -
15 Geor a Y~leidman ~'ertha Sc o;,rrc.
NfORMANT-NAME /TjPe w h..rl MAILING ADDRESS (STREET OR R.F.O. No.l (CITY GA TOYGhI ,STATEi ~~'ti
Paul F. Foltz ~'f'-C raela St. S.J., ::ortY~ Carton 0:^~0 .
f r. AD?:IGiIiM»TE iL i i:•.YL
rwwT I. ~EATiI WAS CAUSED B T O Y f A JN f l ~b/, AND ICI EETWEEA: OhSE7 AND DEATH
u. i - ~ "
IMMEDIATE CAULE w €
- ~ OUE TO, OA AS ONSEOU 1---- j a
2
Cow:lit,wr, iJaq, •+Mirll • i ='°~s
tar[ [Itt ro 6ruwedvl[ fbl - - - - - -
_ ta:I,[, ttatint tlIe r+d[[- I DUE TO, OR AS A CONSEQUENCE OF: -
PART II.OTHER SIGNIFICANT CONOITIOhS: fewQ.rwt[owasarWtSadeaA a.r aqt reLrtd rotrrjtaew M/rtlp/ AUTWSV -lYAS CASE REFERnED TO GORfiwEA
jlYrr er ••o/ f ISpecljr Yo o• No/
ACC-. SUIUDE, HOM.,UNDET., DATE OF INJURY (HOUR SHOW INJURY OCCURRED/E+are rtrrr of M•+rNlrt/w lan !l, iu+, Ia/
- OR PENDING INVEST. /d/trl/j/ IlllattA, Dal, Ytr/ ` ~ M
- 70a I20b ' Xk. M 200 ~as_ -
INJVRY
AT
WORK-~1LACE OF INJURY At AOU[, /ws, Mtr[t. /a[M7. e//le[ jLOCATION /Stn[ta RF.4 wa. [!ry e[ w71V[. tort [1/I _
- IS/•Nrr•, oe aw, {Wh• ele. fSlttl/rl I ~ i
20e f20r. x:61.
To M b by ATTENDIN PHYSICIAN only To w Comaiatad by CORONER Only !
Zta- To tM DsN of TY oc~t a raldau an0 ew to tM alluvia: 72a. fin Ins bans of aa[roaatae analor InasatiF,at.on, w my avan:on osatn ooartrap n ,IIS ta+Ia, .
sutad. u4 wu rw aua a W wllwlsl stand.
/SI(n.h•f awd / /SIO•seue ..ad T)ttel _
DATE SIG O //!a, a1• Yrr/ HOUR OF DEATH DATE SIGNED /Ya, Dar, Yer/ - ~ HOUA OF DEATH ~ -
t. i Z/b. ~ ~ / 21c. b : 0 ~ • M 72b. j7Jc. ~ -
iAOhWNCED DEAD IIfe.. Uej, Yer/ PAONOUNCEO DEAD lHoo/
NAME ANO ADDRESS OF CERTIFIER pNYSICIAN OR CORONER! /T7N w/rlrry /claret wR.F.Q. wo, elry a wBKt rua, slI/
z,.llavid S. Krimins M.D. 60!6 ir.hinule ;~.ii. North Ca ton Chao
BURIAL.CREMATION, DATE NAME OF CEMETERY OA CREMATORY iOOCATION (<ry. N/yt er corwrl/ (State/ `
OTHER/dyetlhl March .13 I .
z.aBurial ;2.b. • , ono ~a.Sunset Hills t~4emory ~rE~'Ode s Nc•rtr. Oli
/ /
NAME Of EMBALMER IUC. NoJ FUNERAL DIRyCT TORE [ ILA . No-.
n-Paul J. La:niell 6 02-A - --1.:~ - ' ~
fUNERAI FIRM AND ADDRESS (STREET NOl ~ {CITY tSTATEi IZli/
- - r•Lamiell Funeral Home 1353 Cleveland Ave h.W. Canton, Chio L~?C'
= ATE RECD BY REGI •S SIGNATUijE • j~ • 'ffYERM1T ISSUED SIGNATURE Oi IERSOh i55utNG iERMIT GIST. lq.
~ OCAL EG. t.// ~ ~
'r
_ _ - -
y