HomeMy WebLinkAbout0331 j
.
i
- !
• '
- ~ -
. - ~VilIIVI\:I•..~16wIi: _ ~..i,~~..,.....
. CERT I F I Ell CUPY Of ;EATS! E°.,ECOiti~ 8 0 3 4 3 E
~ COMMONWEALTF OF VIRGINIA-CERTIFICATE ~3f= DEATH
DEPARTMENT OF HEALTH-BUFi .AU OF VITAL RECORDS AND HEALTH S rATiSTICS-RICHMOND
44Fr w _ ~ -
AFEIEA tiV:F:' A` / NVEEEE II ATE - MEDICAL EXAMINER'S ~;,~;E;.
~s...a:
a /l
C•% CERTIFICATE
L__.
DECEDENT 1 FVII NAME U+10 tw•.eer lu•v 7. S l ..•w 1•w.w a wwcc
OF OECEAEEO
_ C ucasian
~ DATE Of /wy) IMTI Ir•Irl ! AOf IF VNOER l rf AR If UNDER 1 OAr E. DATE O ~ col le•H b•r: T MAS OECE DE MT _
OEATN ~ weww~ T e~vi i•~en T n.Ia.w E•NTN. EVER Ih ut
1 1904 AIIMLO FCIIC EF~ -
~ r•rF i i 1
FLACE OF l N/WE OF IIQEI'ITAL OR INSTITUTION OF OE ATN 1.~1cw.wE, q FYI•r 1 pew a'•Ry ,,,~„r• f..COYhT. O: EATN •1 we•pw4.1 e.er• M•.y
S DEATH (a li ~ 1 ? ? D L ~f~ / (7 -
1Q CITY OR TOtMN OF OEATN . a4 cltr r w•w• Iwu07 11. STNEET ADONESS 011 RT. NC :1F~~.ACE L F DE A'.1
~ UiUAI la. STATE IOR FOREIGN COVNTRTI OF DECE ASEO'S RESIDENCE _ 11 COUNTT OF DECEASE O^S AE: ::`+.CE 1.1 w•e.e•we•n• e.er, I.••.
` RESIDENCE _
OF DECEDENT ~ 1rQ1Y118 _ d~_ _
If i~ II CITY (,AT NOF RESIDENCE c.tragwrw ~+n.I•I IS STA(ET A:1.. •.t55 Op RT I.u ;:OENCE i- :.?C4...
I ~ Y '.c wa
~ s FE RSONAL 8. NAMk OF FATHER Oi CECEASEO 17. MAIDEN NA.J. Of MOTHER : ~ v-.i AStU
t e _
~i ads OATH OF - _
~ JECEOENT
O j+e •Itl CIT 12lN OF MINAT COUNTRY 19. 4RTNF?ACE 1•t•t• r <euwM~ .70 NEVER YARPI=01--1 OIYOPCE.^. IF U,R . _ ~ nA N:7~~:•=~, A3 JS CF 5.O..a'_
/ 2 nE II ~ YARwIED? w.DDMED~ Tti..~.1C~
m ~ ~ aa. SOCIAL SECURITY NIN•EEP 2a. USUAL RlAST OGCWATION ilI KIND OF 6uSINESf ORINDVSTRY 7S INF pp•J NT JR SOUwCE .:i INFOpIFATION -
a 'i -
o 3 • • ~ 7 .s Franco brother
' at. CAUSE OF OEATN IEw•r owM ew•{•yq 1•Y Ia tAl, /U, MO ICI. .Ni(er°..• '
~ ° TART OEATN TFA$ CANED •r: _ :+ASFT ANG I.
~ e u IYUE DIATE CAUSE tAl ~~I ' C ~l ` ;7 ' l I ~F~V M Iii / ~ / ~ F ~ 7
. c
Z - - TO
F.~ OUE TO
' o o MEOiCAE -
< LiY Cow°.LO•., •f 1?•r. wlLCw G•.• ••w IBI r
X c EXAMINER: +e .••.•..•e.•u cr•q IAI, luwy aI•
~ 2 w!w.lr~+J <wg uu
` O DVE TO i -
°e cr...r«w r IcI
~Male•.•.••w• < FANT If OTI•EII S•:•\IFICANTCONDITIr~S CONTRIsVT/Nu TO LEATr1 BUT NOT I•iIATED TO TNC 'ERYINAC .M•PLTC~SY> rn
I Is+74NM••+ FJ DISEASE CONDITION GIVEN IN ~AwTI/AI
- 7=••Ir I•N.•r•• ~ - i4U'nJ?IIED'Y rYy
~ f r..I.•..r. ~
~ G ~76p I= iEUALE,W+S TMENE AIRE4NANGV 76c IF ErtTE RNA.:i.~$E. IT YY AS 7do :Jf SCR.di ••O . ~'-.-F? RE LAT.'. -a G'•1 J=Cu
Z E w .N OAST a MONTHS/ ~ r.u.••• ~ ~.u+••.l.i w.r, 0 ~ cL
l V .o c..Al oy o•.:..
~ a s J rn ? ro D rw.I•ew••D
< 7M. T.ME OF INIURV Iww 1 le•TI /r•rl X1. INIVNT OCCUw aEO 1769 ACC OF IN.v I+o.e.•_ Ir... ..n a ;y Jr IOww1 /ewety. .eT•.
! F ~ I.OrI I• ~ V A.M •rTwr, ro«L et•.u deg. •r_1
a,.•.w w 1.M. •I wv. ? wr. ?
• =I•
w ....w 76• t = .rr~a re+••.w• •1••a..4•J ri°.•. • Vw•.: VN e.:~iy, ^••u .ei.•••• YO w.r OY ^ •r.. 'M M :A •4 _ ~ =k rY1 . •O+•
NATVPAI CAUSES 4 EN •-J+'•GDE l , UN,~?7E FM:N?' +:_yryr.~: ~ _
Ir - - --------------------Tos'.s
- ACTUAL- ~ cG •
f SIGNAT UAE ? S ~ I _
_ ~ n /7 `
' NAPE OF MEDIC EERAM.N Isw.wwr LL _ _ - .L_ - ~ Y,,,I
TPOO~/GF VED.CAI ExAY:~ ? / /
I~ FUNERAL aT' ~VRIAL NEMOVAI CREMATION 7° (LACE /.,,fw.,r.•or,. .yry°.~...+•q... Ic.Iro....-, .•I
REMOVAL. ETC
DIRECTOR ~ ? ? oc euplAt. r'~. Comfort Cemetery, Ale::s.. ,
j h. Es.F,,..•....r..,».r...«q.°...n•..w-..°.wE.w..l«.....,. ~_.:_~::,•~C'? I- :'2.--~2~'~.-L':~3w:~
{ HOME A'. ~J~
? ~ ~ .DDpEU`1500 W. Br.:3ock P.d. , Alex. , Va.
- -
REGISTRAR ~ _ Nr•P•~rI DATE RECOwp
T
> ,F - ~ ~ / t~
f, .LIED ~ ~ J ` .
This is to certify.. :;31$ a true and correct reprcduct~ oc the o. i~ir. 1 :e- filed
with the Arli . • •f~sieki ~ Human Resources Arlington, Virg nia. •
.
i ' ~
Date Issued
~p j•a;~ Registrar o Deputy
(seal) _ . 1_~-~
l-, ~~THI. ~ hiENT '~'Y ~T:'-`~"'~'-~ _ ~ ;.~C~i i
ANY REPRODUCT ~ (~3 N: I S PROHI3I'i EO ~ _ 1 L • li
UNLESS IT BEARS' '~4~GH~ SEAL OI(' Ti:E Ar~LINu1C;r D::t Ai~T:•:E : _ C-
RESOURCES CLEARLY' AF~X~' ~ ~R
CArt i nrI '~~-~5~ .27. code of ~'ir~irlla, as Atrendea • BOOX~S PACE ~1