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v: ~ ~ _ - _ - - ~ - - - - _ _ STATE OF MICHIGAN 4922
DEPARTMENT OF PUBLIC HEALTH
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STATE FlLE NUMBER
0 2 5 2 7 3 B - CERTIFICATE OF DEATH
DECEDENT NAME alsr ~roolt usr SEx ~ DATE OF DEATH /AIa. Day. Yrl
~ Josephine (Zemenick) Pluta iZ Female !3 11/02/78
RACE-a,. +w+~ s~ AGE-ur Mrvw ~ N , Y + t AY ~ DATE OF BIRTH /Ma. Day. Yi.l ~ COUNTY OF DEATH
«e~ iSpaerhl IY~s.I ~ws wrs «gsis w+, I
White ! s,. 77 se. , ~ sG s. 10/25/01 Oakland
LDCATIDN OF DEATH J ,r,ps on ,yr„s a, Troy I HosPITAI oR OTHER wSnruTK)N-w.. •,+.r u. «r.. usw w ~•.r..,
IGeek one ,
ae0 °p"~" ~ "'~°""""`E `"rn i William Beaumont Hospital -Troy
)0. rl rwr d ~ 7c
sett a ,wrw .a uS A ~ GTiffli Os WHAT O~NNTRY ~urreED. ~EVEr ~ulurEO. SURVMNG SPOUSE /N wrht grw madam nxrNl was aEtENEM EvEr w
a oEwn~ -•w cwrrrr ~ I wooir,a. onorOED ~Srcrn ~ u~~IrwEO sorCESr
e. W 9. ,o. None (Jose h) IIQid'
SEE a~olra SOCIAL SECUgITY NUMBEII I USUAL OCLI/PATION /G.w kwd a/ work don, dummy mast or KIND OF BUSINESS OR WOUSTAI/
~ECrroe~G working G/e. cram d ntradl
rE~w ,3. +w- B ~ Beaut Sho
CIJIYIEtdT IIESDENCE-STATE ~ COUNTY ~ LOCALITY uKiOE Crtr WrTS Ot rOy STREET ANO NUMBER
~ ' anted
lkPauhl a +rS~DE vaLaGE errs os
,S,_ Michigan i,s,. Oakland l,s~. .w. as ,4666 Chapal
FATHER-NAME Rrst ~rapLE tASr yMOTHER-MAIDEN NAME ra4sr w00~E t/~Sr
IB. Michael Rozanski -Anna Salewski
WFORMANT ~ MAILING ADWIESS srrE[r a r t o Mo. • arr o, rowN srsrE aP
,8,. tu,., Ca Z ,Be.4 6 ha 1 Tro Michi an 48098
~ ~ row 19. IMMEDUTE GUSE (ENTER ONLY 01vE CAUSE PER LINE fOR /al. (Ol. AMO Icl-l ~ nrrvr eN.w e.w w e.Nw
S~
~
~ PSI,,, Metastatic Carcinoma Primare Site Unknown 3 months
~.iOErtrwG DUE TO. OR AS A CONSEQUENCE Of: ~ nrvw ,Nrwr e.wt w «w~
cwSE t/~ti
~I ~I - I
iel ,
DUE TO. OR AS A CONSEQUENCE OF: I rw.p eN.w a~N w a~.e,
~ ~ id •
~ - PRAT II OTHER SIGNIFICANT CONDITIONS-tweow m.rrNw, x www ,N ~ nwr a crr err rarr ~ j AUTOPSY fSpstOy Yes t WAS CASE REFERRED TO MEDICAL
1 w Mvl ' EXAMSNER! JSPeaN 1'es or Ab/
Arteriosclerotic Heart Disease, Congestive Heart Fail Yes ~ '2,. No
PUCE OF DEATH ~~wwa ws.y ..o1w.. t i NOSP. OR INST.. uwort ow. ' 2W. ih crM ,may „y aN.nw.w .o w a •..eca wwr. cw
•a.... I hl ! v-Eie... w....n... ISpealyl •fer?
n,. ~osp~ita : ub. Inpatient
F JO.r f , O. ISM oY~ M tlFeMOO~ Ir~Or wMC~i00~.. ~.I CV~O~ O.~M OCQwN N ~M
j 23,_ To er e.rt d w ~e~+.Ma w~e~ oec.•.M N rr u.a sw w aw w aw w e.a aw w wo w ~w ro w cwwa aNw
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p Z lSiynaturr srrd TiW7 ~ t JSiynxun snd TrtMI
> ~ DATE SIGNED /A1a.. Day Yr./ ~ HOUR Oi DEATH DATE SIGNED /Mo.. Da,; Yr.; :HOUR OF DEATH
'N 11/03/78 3:10 a.m. a~
v: s 23b. j 23C. M v < 2a0. ~ 2.c- M
IW,1~ NAME OF ATTENDING PMYSNZAN IF OTHER THAN CERTIFIER /Typew Hrnp ~W PRONOUNCED DEAD JAEO_, Day Yrl ~ PRONOUNCED DEAD iHoarl
~ 23d. C/ 2sa. ON 2a,. AT M
hAME AND ADDRESS Of CERTI ;r..rS~Gw Ar 11EpCx E7tAIrrE14 (Type orP?wit/
2s Todd C. Gould, D.O. 455 S. Livernois Rochester, :rII 48063
+CC_ svooc ..or. wT»rAE i DATE OF INJURY lkao., Dal! Yi./~ HOUR OF INJURY OESCR18E HOW UiJURY OCCURRED
E Or TENa1.r, rwEST. ~SO.c.h~ i I I - .
NJURY AT WORK PLACE OF :NJURY-u +r.a h~r...r~ ansr. dM ~ lOGT10N srrEEt On •t~ wa on vtllAGE Or rawuy~r ir~tt
lSptaly Yes a Nol ~ •..ra we ISpeadyl
j 2h. (26f. ~ 26q.
BURIAL. OREMATKN'1. REMOVAL. OTHER ~Speal~l ~ CEMETERY OR CREMATORY-NAME ! LOGTION on. vwu~cE a rowtis+.r sT,~tt
27,. ~ 2>s. R r ~ 27G Clinton Tw Mi ch i an
.
GATE /Ab.. Dar Yr.; NAME OF iAQLiTY ~ ADDRESS OF FACIUTr
27a. _ _ ~2Ba. ':eo. 9 Hoov r~ Rd. Marren 48093
8-38b WNERAI LICENSEE REGISTRAR ~ DATE RECEIVED BY REGISTRAR ikda. Del;
lS+ynxu /Sgnxunl y~l
I, f781 ~ ~ 29,. ~ ~ :29b. 7
! ~ r
s;: . , ~ 1950 ,1y1. 9 PN
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KEN.. ~;t'H .L C~U~T~IEY, ~CER ~ IM ~ ~ 492222
'•TROY~ ~N~~H~GAN - ~ ~ _
: ~ • BOCK 334 P~~E 15~i8 ;
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