HomeMy WebLinkAbout1441 ~ J STATE OF MICHIGAN
y~;.a?T' DEPARTMENT OF PUBLIC HEALTH
STATE F11,E fE1111ABER
. , 986803
9 B CERTIFICATE OF DEATH
012 3 6 8 MISER 152 PEE g6~
DECEDENT NAF~ cElnsfT ' wooEt E.:t sEx oiATE of--~__EttATH /AES.. Oor. nJ
.emu Di ~ct~e x. ~QKr~ 2/,
RACE-r• ww. w.aa w1.« AGE-~+,. a+M t OATS OF OIIRH /Aes. OrM. ri./ COUNfY OF pEATH
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s°a°~' B.. ' ~ wY: Howe E.11s Feb. /92/ /~larti.atee
LOCATION OF DEATH 11N~1E pry uw1Tt OF: IIOSPITAI OR OTHER eiSTFi1JT101'1-1wu /rrtrw«. rwrmt W..+r«r
and sprcdH .1sbE v.?w0t wit. or:
o~. ? i lgea# .Sfiv~.e ~ /rv.ooi..ta~l
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• _ • • awllwEa NEVE11 rwllwEO. wws oca t» [vEI1 M ~
:TAR a w11TN 1r w,1n usA CITRFN OF WHAT OOFMAIPt SURVNWG SPOUSE lM eviAE, lir+tnaidrn nawlrl us wwEO wsast
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N OFwTN M • M Ay
occus•EO N B. B. 10. ~ • ~ 11. /7 T2. ~ .
MISTRUT10Tl
sEE TlA/wlwL SOCIAL SECU TY NUMBEII USLAAL OOOUP~?TION lGJw kind a worn ~ dutiny atotE a/ KIFIO OF BUSINESS 011 WDUSTIIY
corn[T1ow a ~ -
/ /4_ a4/4 .S7ceet Alva ° ~i~tea R ,.b.. Da o `
11ESOEa:E~ ST~ET~ND; UM,ER - -
CU1111ENT RESIDENf~-STATE 001M1T1? L IOCALtTY rgoE ulr LrE1ts of
/?li.ciu'.gcn Loge aP+~?~+~«,nEwcEEaEffseE
Tea TM~ os Sau6.Le Fej/~Dn~ -
FATNER-NAME trait EroolE Wt MOTHER-MAIDEN NAME t11KT YODEE aAft
Fs. Ro.4UP.,u TT. LtLG4Qe ~ PJl.O
MIFORMANT ~ MAILMIG ADDRESS itllEEt OR At.O. N0. Gfl1 OII TOIIYII fTAIE ZI
ts.. w.! A) L TBb. / 1/~DILOy /ht.c~ai.ocn 491644
" "'11rt 19. B1fIEEOIA CAUSE (pVTF/t odYEY OIYIE CAr/SE PER [IAFf fart /IrA AAFD !u rrn•1 w1..w «.......r+
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we1xATE PARTI ,~C - 1!Q-lL. L(r~ ~ l I f~ ~ {
sTw1A( T11E
I ullotra•r+G OUE TO. OR AS CONSEQUENCE OF: I rr a•w.
- cAVSE awsT I
L_~ NI I
DUE TO. OR AS A CONSEOUENCE Of: I)'r"'M wt"•" o..« ra
I
. ~ • Fd _
• f~ PART R OTHE SIGNIFICANT CONOITIONS-p•~rs.1 a1••~nE r b•r M w•1 wMM r ww.. ?AITT ~ AUTOPSY /
~ TTtf WAS CASE REFERRED TO MF OICAa
ExAMWER7 /Sp+aly Yq w Ab!
F HOSP. OFF wST.. races Dora 24a. .
PLACE OF DEATH 91•'.•. N.w Nr.a ~ 1~ .•.r+.N w U•lrrw•a w r M . rNC•1 w.•w• ew
22a. ) I ~ 7 ! \ t2b- / l.t a~ ? ~ eo.l O a r ws d ...wr...w« ~..M~M+ti ~ •o N•~w ww~ .caw.w M M ' I
23a. 1 r.• b e1 1 •.~er••~y~r•1O Y M M t•r M MIC..Y M r w Mti W p•c• •rr M r W iM•NM M•ur
O 2 lSgnituie aad TiEM1 I?~ ~ lr I
i lam, J t fSrgnwturc and THAy
- Z < OAT SI~GJN~ED /AIa. Dry, n./ HOUR OF DEATH S - ~ i GATE SIGNED /AID., p1. Y1'./ HOUR OF DEATH
2~ /f 1 ? 2k- ~ Sf- ~ M w< 216 2~c- M
` vif NAME OF AITEN PHYSICIAN FF OTHER TH/W CERTIFER /TyporP?int/ PRONOUNCED DEAD /Afa. a1: Yi/ PRDNOUHCEO OEI?D /Nouq
23d_ 21d ON 21a. AT M
NAME ANO ADDRESS Of CERFIFIEIF pNVS1[uw ol1 YEDICAt E:1iErN1q /Tpoe w flint! /
wcc. su+coc .a,1. wa1{1Ma IOATE OF /wE~RY /Afa, al: Yr./ TIUl1R OF IN.NIRY DESCRIBE NOW IIV.JURY OCCURRED
011 Ifw NVES~T_ ,Sri , - -
zea. l~u?~ ~ z66. tea zea
NJURY AT WORK PACE OF INJUR1f-A1 r..•. 1•rwa w•1a. 1••T•ry. a11u lOCA7FON sT11fEt 011 •to. NO otr. vwlwcE. 011 TtwNgSNr s•w•1
/Slletiry Yts or Ab1 e•+r~a rc lsPEC%Yl
28e 261. 2 +
BURIAL. CREMATION. REMOVAL. OTHER CEMETERY OR CAEMATORY-NAME LOCATION prat, v1?awGE. 011 towls..r stwn
i~", i3~cai.alC 27b. Kee[ea (eM. 27a KeeCe~ Trop. VotlS.ca~i~oi`~
~ DATE ~ Yi.! NAME OF FACILITY ADDRESS OF FACILITY
l~raaclt 25, /9 e{~1c~C.auch,Cur. C.La/rft FunezQ,C Horne 286. l,~uxx~ac, Akclu~at 47 _ '
B36b FUNERAL SERVIC~IICENSEE REGIST • DATE RECEIVED BY REGISTRM /AIa, D+,c
(1/78) /Sgnatu~-•~ ' lS~+++t
E 28c. 1 28.. 29b. ~ ~ ~ ~
S / f
1 I, EMILY IVERSON, Clerk of the Circuit Court of said County of ~
~ ~tdtt of ~Iitfjigatt, .
~ a Manistee do hereby certify that the above and foregoing ' true~?d correct
. ~ transcri t of ~ r
r~..3 P n
ti.
~ -
l f y~
stL
F ~ R POITRAS T • ..N ~ A'
r + ~ i
'y' . ' EJ ti D Z ;
g - - s+~ compared by me veith thc• original, now nn mcord in ~e _f jic~ o~•the C_!~ i
t
E ~ ' , • ~ ? ~ - of said County and Court, and of the whale o[ vrigi~l, rrcbrd. ~
In-Teat Q W ~fleof, I have hereunto set my hand and official seal at the City of Manistee; in said
. + ~
col; , th~a - -day of fl~ - one thousand
E nine hundred and EIG~I'Y .
Co. Clerk
I
RECORD WITH REFERENCE T0: - - - • - - • !
~ !
Lot l0, Block 1195 of PORT ST. LUCIE SECTION 8, a p
Subdivision according to the P1 at thereof , recorded i13ER~5~ ~ 6C+
in flat Book 12, Page 38A, of the Public Records i
of St. Lucie County, Florida. 1
8331 ~d~Ei44i