HomeMy WebLinkAbout0018 4£~59r75 - -
~1ON P,ECEI~fEO ~
DEPT Of NU~~!~ PESuURCE~ DISTRICT OF COLUMBIA
DEPARTMENT OF HU11iAN RESOURCES
e Mead 199 ACT -S r~l l~ LO
ificate CERTIFICATE OF DEATH T9=006385
f_n~uy YIT'tl ~ECOROS SECTI~H .
nLS Dwis Pu. Ne.
1.NAM[ OF DECSASED Jnnt Jttddle Last ta. DATt Monts Dey Yssr 120. Rout of Dssttt
em of in• t~M ~ s~st) ~~TER EVERETT AYER3 DsoeiH OCTOBER 2 197 12:04 PM
S. SsX d. COLOR OR RACE Nsses Mesled. Mstsied. i. DAIS OF BIRTH AGE Qn ytera a
n should be CAUCASIAN wido~e~i~~= S~dti ~ DECEP+IDERl 10 IartltitMdp/ etatt/u . oa++ iet
supplied. S, PLACS OF DEATH IN Washington. D.C. USVAL RESID6NCt /11'Atn dteeaeed Itwd. If tnstltutton, nsidtnN
NAYS OF HOSPITAL. NURSING HOl[s OR OTHER INSTITUTION a. D. COUNTY tNlotst edewwia+)
UI got to iwsdtutton, sine •enet eddnt+l ~A~eH CAROLINA
1NSrDS crrY LnaTs
should ba WAL•TER REED ARriY MEDICAL CENTER a. CAL 2 200 ~ tsesctZtY Yss oR No)
w r i t t a O d. STREET ADDRESS ' I! N~ Ioeetiow/
fed in per 234 VIACENNE ROAD -
t}•pe black 10e. USUAL OCCUPATION (Glee kind o! arorR lOh KIND OF BUSINESS OR ll. 1lIRTHPLACS CITIZENOF WHAT OL'~iTR
ne darins m o of en 1- ewn tend/ Y ISrats orlon' n eowby) -
I~TIFyD v~i~ S~Ci~s~~$ s~ ~ t~'`p~~.~` :ENr-FSSE~ u~A
13e. FATHER'S NAIjt6 l~h !MOTHER'S MAIDEN NAAIi AM O I IN S 'SE
R US R AVERS LETTIE BOLTCR A A
-titicale be- 1lt. ErerisU.l. SOCiALSECURITYNO lTa. IAIFOFhtaVTRB(a'r?()!vesryP'^^!tEC£~elSED1TL. AC3RL.iS Stress :.isy gaffe
permanent A"'~S
°t"`T 2 1-64-0 COY E. A7Cb1iS BRO RT 2 LA FOLLE'ITE TENA.
~cotd when 1S. CAUSS OF DEATH: IEnttr only ont Cause ptr line ;or (t/, (b), end /el.) Iaterral Betwsea
' ezecuted. PART L DEATH WAS CAUSED BY: ; Onset gad Dsatb:
D41MEDiATE LAUSE (a) MYOCARDIAL INFARCPIOR
r
CondiHonr, t/+nr. 1
tattlcA sew -rta ro Dva TO tb) ATHEROSCLEROTIC COROfiARY ARTERY DISEASE
- _ -
to submit a ,'L ersooe sews fo), sot- _
,te of Death O ~t At wdtrtyles taws ~ _ _ - I
Department a Dus To tt) GLO~~RULOSCLEROSIS
umifi Ra- U PART II. OTHER S)GNlFICANT CONDiTIONSs eontsibullna to death but 4ot 19a. AUTOPSY' 19D.IlYss,Were FiadiasaCoaadeted
I'' vela NLPHROTIC S7tNL'ROME iUos tt.sa m part [ ta) _ YF~ oR No in pete:miaias the Ca,s. of Ds.tst
{Cl t.teln -
sfter death ~ IF OPERATION WAS PERFORMED 20a. DATE OF OPERATION 20b. CONDITION FOR WHICH OPERATION
io'.ation of W C011lLETS ITEIH.S 20a and 20b WAS PERFORMED
U
of the Dirt .i la.Specilf it aeeidsnt.sureids.homi• 21D. HOUR ADiD DATE Ol L~tJURY: Month,Dat+.Yea: 21e. DESCRIBE HO WlURY OCCURRED
Columbia. U dde. of magnet undstetmlaed ll (fnttr nature o! Injury in Pert I o? Pmt Q)
~ 21d. INJURY AT WORK: 21e. PLACE OF INJURY: (At Hoent, Fcrnt, 2>lj. LOCATION - CI?Y COUN?Y STATs
Iv (Speedy Yet or Not Foetory.Stnetor 0/lies Bu~7diny, 6ta? ~
BIER ~
OUT 22.I eettrty that N) (this hmptt}I) ~ a deceased =ygtn 19_~. W ~»Q~.Q~~$._... 19»~Q . thatYi) t~.e) )ast
"THIS mt7 the deceased alms oa 19 ,and that death oeeutsed hom the causes gad on the daft gad hour stated aLors.
SPITAL". sl v 22b. DATE SIGNED
PHYS.yD~G DIRECTOR HYSr ~ 3 OC?OBER 1979
22a P YSICIAN'3 ~ 22d. ADDRESS
'i of these NAxEt'hpe> W. RIP Bp1L0U .TR I~ CPT I4C 682 16Tfi S ~i'd iJASH D.C.
`f ~ unishable
~r imprisoD- 23a. BURIAL 23b. DATE 3e.NAllEOFCEhtETERYORCR~tATOR 22d- I.9CATiON r!Yly.!ou•~,orec+~•~!Y1 (State)
50~• REMOVALN Oct. 5,79 Woodlawn Cemetery La Fol te, Campbell, Tenn.
2s. TUNERAL HOME 'ES RINALDI FUNERAL fi0ME 2 R?My R'S ~ E 25b. L'NDF.ItTwB:ER'S
wDDRESS 1800 t'E~T HAMPSHIRE AVE. SIL SP MD
r rr NU*.1BERA
REMARKS:
Authority is granted for cremation by
Medical Examiner or Represeatativt
- - Date: -
--t.
'sl~.~i+.- r:~.¢ = - - - - - -!Sa- a...• ~ e y - ~ _ -ie-~~.. _ ~ _ . - - - - .-.-'tea+-
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_ 1 CERT 1 FY that the above i s ' r u~h{~c~~r,~ect reproduction of the or i g i na 1
' cent i f i~cate f i 1 ed i n order .w _ ~ ,1~''r~1~~ecords D~ v ' ion, 0 i r i ct of
} ~ ~
-Col ulnb i a 0epartlRent of Pub , .i'- t. h
DFDfl~ER 18, 1979 t - -:k4 . o n Cranda 1 1, Chief _
~ Date -1 ssued NOT V~L1 l ~ . 1 SED SEAL Y i to 1 Records Division
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3 ROGER
POITRI?S
CLERK CIRCUIT Cat!
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