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wsTaeco MEDICAL CERTIFICATE OF DEATH ~ ~
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[ICCEASEO NAME •Iw?T rlooaa uaT SE% OAT O A N trorlN,oAT. Ta.wl
- ~ , Jamea B. Steeples 2.Male 3.October 2 1979 . !
~ wAC[ AnlTa a. Atw Arawla Ar RIOIN OR OCfC[NT AGC awaT VNOCR I YEAR UNOCR I DAY OATC Oi OIRTN IrO. c..T, Taww1 COVNTY 01 OCA~Y
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• Oa O T NOVw rlw
I 4a :ihite ailmerican sa. 62 sb. sk~:arch 14 1917 ,,.McDonough
CITT, iOw w. 7w1. OR WOAD O•aTRICT wVaaOaw NO$IITAL OR OTN[R INLTITUTION R.r[ Ili ROT Iw aq Na R..IYa [T wt aT V Nov. Ow INTT. .w..c aTa Oa,
wR0 wuraa wl wlca.cw. waa •r.al•arT la.aa•i.)
rt < , ~b 1`acomb ~~McDonou h Di stri ct Hos ital ~d. at ent f
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us. w.ra aouwtwTl MIOOWEO. OIVORCCO t[i[clirl
1 s. I~; s r ~ SA to-1~1a ed 11- a Bower
fOCIA? 1[CYRITY NVNOCR USV AL OCCUiAT10N RIND 0i eU$INCSL OR IN OUSTRY V f TTAR VETCRAN MAR OR DATCf Oi SLR VItC
IT[a~nol
' t21{ P,-0 - 4 tSloft Drink Dis ~~.butor I~[Xe:~ ~I~.~r.II
R[S10 [NCC aTw[aT wwu wurwaw arT. TOww. Twi O~ROwO OHTwKT we INSIDE CITY COUNTY STATC
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iATNEN NAAIf iuN r•ooa[ Ew[T MOTHER YA/DEN NAME TawaT rmoaa a.aT
,s. Arthur Steeples ,s. Florence: Hummel
1N1 allTYANT'S iG11.NATU1!/' IILEATNINSINw MAN INf• ADIINI'!S I•INIIT wrllr00••u / II,I ITT nu I•IrN ?I.II I•.I
,ib':~ife „x±14 tV.Calhoun,Macomb,Illinois 6145
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( -t8. DEATH AS CAUSED D ICNTCw owaT ONE cwwa •cw uwc row,i,, lbl. w..o ICIt ca. w[[N OtisaT .wo oa. rN
1 PART I. IaaM[DIAT[CAUSC
+ tat ..cute bronchi/~l asthlnl ! a-
' CONOIT:ONS 1f ANY, OVC TO. OR A$ A CONSCOV CNCC Oi
Y/NtCN GIVE RISE TO
IYaIE OtATE CAUSE b) ~ _
STATING TAE UNOER~ IDt Cl:r~nic Obs`2'alC ~1 ~T` ~ ~3' •-r
LYING CAUSE LAST. OVE TO.OR AS A CONSEOVCNCC Oi
::2tr<mic r:.s;,ir~.torv iailur~ ,yrs
Ict
PART 11. OTHER SIGNIFICANT CONONTIOINS~ cowTNln. cowTwwTUT•rat: To xwTN tTUT T.oT waawTC:a to cwuS[ uT[N w i.wr 11a1 A VTO?SY • T[$. ra.a .r•aroa ca.
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~ Ta: ~.fi2'1~.:;CiP.21G`iC hC~2'~ UiiC:~"3C OVcI':iF.~ 19a. O t9b
j OATC Oi Ow[RATION li ANY MAIOR i1NOINGS Oi OwCRATION _
20a. 2ttb.
1 ATT[NDEO TNC IrowtN, OwT, T[wwl IYOw1N DAT. Ta.wl w•.O Ew1T awT. nlY• IrOMTN.OwT. Tawwl HOUR Oi DCATN
O[C[ASED TROY TO ~ naw wuv[ ON -
2ta $-li-/~ 2) 1('-2- 2Ic. zIe8S50 PM
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T••~ wNT O. rT wnoru OGt. o[ATN CcVwr o wT nN[, uwTa ANO K.CC w o ou[ T07 c C.usatTl aTJT[D DwT[ SIGNCD 1•.OrT•• owT T[. w;
y
_ to-!~e79
{ 22J SIGNATVRC / \-~Q- ~ t - _ 22b. _
r~ IIwVa At.u ADONCSS Oi CCRTIiI[R tT /TK Or M•w I ILEINOIS EIC[NCC NUMeCR
s2~ 1~. ii. I3orun;, A:.D.. Blandinaviile I1 bltt~0 nll. i
NArC Oi ATTENDING PNY$ICIAN If OTNCR THAN C[NTIf ILR {T r.[Ow ir•rT1
MOTE. IF AN IN AIRY Y/AS INVOLVED IV T./iS OFATH
THE CORONER AN/ST BE NOTIi IED
?3 ~ -
Ot.NIAI. CREI.A TION, CCMCTCRY OR CRCr ATO RY -IJAI.TE IOC ATION cD T•aD tO wR ttAtc DATC IN,:r tn. Gw• +t.wl
24~Burial 2Ab. Black Oak 24c, tdemphis, Missouri October 5,1979
it•TI[RAE I<OYC NAME frwt[T A••o nurwcw ow w / o. urr ow Toww s*wT[ cv
2s3Dodst~orth-Piper-:>rallen,201 :Test Carroll Street,I~iaco!nb,Illirtois,61455
iV N[•/A: DIR[CT 1 NATURE rur[w.EO•w_clcto.~slulwols a•ccwac +ur[[w
' 25t/ . 25c. 5J'+9
FOCAL R[4~$~RA 10 ATURC
OAT[ R[CT) eY LOCAI REGISTRAR IrOwTN o.T, T[wwI
~ Macomb 26b October 4, 1979
2Ed
vHtuo INCV. t,:3 IIGtIDIS Departrnent of Pubi~t Health - Olflce Ot Vi1a1 RttwdS Iwws[o DN n/[ us srA«oAwo cunnu*et
3
~;TATE.O~. IS ) .
~ -~f t.'` , ~ (~TIFICATE OF DFA'Ili BOOK 1979~'~GE 249
RJ
i •
s DF~S, Oc~unty Clerk anc~ Recorder of said County •do hereby
as hereinabove stated are true and correct according bo"
+t~. , of James B. Steevles as made fran the
• ~ - of deat~t.
Hand and Seal of the Recorder of said County at Macatt>b, this
, A. D. 19~p .
F
Signed _
(S~~ ty Clerk Reo~ er
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