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502399
' "-~-~""'"N0. REGISTRATION ~ie~
DISTRICT NO. 49 , 7 TAT! OF Il.I.iNOt!
REGISTERED 178 MEDICAL CERTIFICATE OF DEATH
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t....:Y r:..r n OtCtAStIY-NAME a,rsr w~so~t tr~sT SEX DATE Of CtAlf1 u~L+rtiwr,Ta..?
4.~i~Aw .F~ C~: scb,t; Gerri tt William DeVroe
t Male a June 4, 1974
r:.. ..r•.,caRi
w .-u roa RACf rw,Tr.rtoRO,u,tR,car uo,ar, AGE-asT ,UNDER 1 YEAQ~i_~:aFk pAl' OAIE Of BIR1N (rorTN,wtr,rnU PULE OE' G:AUt co+'**
thifiv~liONS ttC. lSalCUr? - NRINO.Y (tRfJ N03. WIf M4.,Ra • N,r.
pTr, IORA »?tOR RWO D~STR~:t M11NlltR~• ~Sb~D[ C,TT ~
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Yy- - 7b. Lake Forest ~7cYes •7a. Lake Forest Hospital _
~ f3lRTNPIACE lsuu ow wnwr CIT1IEN OF WNAT COUNTRY MAiRiED. NEVER Ms,iCtED, iJMAE OF SVRViV1NG SPJ1)JE Iwst~ tart, n ruy
CouMTRI? WIDOWED. DiYORCEO ca?cursl
3-_______-________ ~ Holland y. U.S.A. )o. Married )1. Glad s Mansbrid~e~
SOGIAI SECUR?tY NU?ABER USUAI OCCUPATION ~l~NO OF tuLUESS Ot luousttr ~U.S~W//1R VETERAN WAR Ol UATES OF S_.::':~
_ 17 347-24-7327 130. Foreman i13h.Golf Course itx. No ~1~,
RESIDENCE srac ~ cou+Tr ~ un, Towr, oR Ro.o osn+cr Ra. ~,NUar pTr [ aun.ro Nurata
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1e0. Illinois :14b Lake il~~, Lake Forest ~l.a.l'es ~ue.1335 F.d ewood
' " FATHER-NAME r,RS, r,oau vsT MO1EiER-lAAiOfN NAME rust r,o:.at ~ a•ara~~
is. William Gerritt DeVroeg is. F.1len Johnson
INfOAMANI'S SIG~IAIu ~Q ~ ; kEIAII~~tStiP ; MAI;iNG ADDRESS lsTRCtr •+o wo. oR R. r. o-, u:a ow To.R, aTSs~A•?,t5
n.,~ eK.o .e%~~. antr.Records •l~~fi60 N.Westmoreland Rd. Lake ForeUStU4LT11.
18. DEATH WAS CAUSED BY, (lNlq JNIr ONE C.t71t •E! L~RC tOR GI, (e?. •RO (cl) sar«i~ti c.niT`i ,i• ~rw
PARi E. a,arEO+wl[ CWfC -
9 Tol Carcinoma of Prostate with widespread Metastases 2 years ~
oat to a ws w wrsaoutru w.
3 months
ooro,Twrs, w .rr, t0 lungs and bone
tN,CN 6,rt use To Ibl
_ .NN000rc uwsc Iq ouc ro oR ws w w+scoucRCt w.
~ ~ RTI.r,r6 TNC UMptR•
1r010 GAOf[ iJ~RT.
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4 _ _ _ _ _ _ _ _ _ _ PART 0. OTHER SIGMFICANT COND1110NS, toNaT,aws coNTnRUTr,a: To otwTr wr wor Rtaw~tn so ceust e,rtr N r.sT T w AUTOPSY r + YEf. .a.a ...w.aa a..-
Ins/rOF .4ataaG aPaa,...aa c...at }
' aM ta...YeS
3--------------- ~ 19e. Yes •195.
DATE OF OPERAl10N,IF ANY ,MAJOR FINDINGS OF OPERATION
rz______________ X00 March S, 1972 Carcinoma of Prostate
P t AIiEND:D 7ME wOMTM,OAr,r )NTN,DAY,1tAa? ~.~ouaTS..,. ro•,r,a,o.r,rcnR? ,HOUR Of CEAlh -
DECEAStD FROM. TO . NcR cant ors ,
210. March 5,1972 ?lb_ June 4, .1974 ~s1,-. June 4 1974 ~~te. 7:30 P.
!CERTIFY THAT TO TIIE FfST OFSlYJrJ\OWLRDG6THlS DJSATHOCCURREO NOTE. IF AN ENJURY RYAS INVOtVFD IN TF+iS DEATH,
ON TllE DATE. AT TIIE 9'/Mt: AND PLACE, ANU FROJV TIIE CAUSEGS) STATt.'D THE CORONER MUST BE NOTtFCED.
SIGNATURE I' rDAiE StGNEO INO+TN.oAr,rrwR? altt:NWS ltCENSt NU!•1SEk
n0.® T2 il/~I/.v June 6, 1974 ;n~ 36-21646
JNAllIt1G A [SS-CFk71i',FR fTR[[T 4RD A~N)[R O. R. O. GTr OR TOr.r RnT; z,a•
210 East Westminster Lake Forest, Illinois 600485
BUfitAl,CcEMA1tON, ,CEFAEIEQY OR Chit TORY-JvIMF ,IO~.AiIUN ~r.oRTCwr suse .UAif UwwT.e,owr,,wl
REAlOY11l tsrcur
se0. / J ~ s~5. G/?L'S1F" ~ ~ G'r-i ~ a4e. ~L'~
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_ FUt~EF ON.E _ NAIAE sTCa[r.+o rurscR oR a. s. o. a oR Towr sT+TC ao
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~s01 ~ ~ Si ~ v-. ewe`i~/~t1G /'l<f~1~~C-A/-~o/d,/~~ .~211e' ~F'Csf~11 ycI r lGr-~~
FUt~E2At~RE O ~ StG:a~.1TE /!f ? I~ ,ru::tw az:,[~:s~s ur~~o.~:KExif n:wrete
lOChl REGISERAR'S SIvtiATUiIE r,~~ _,vAlt kt G. BS IGCAI k[b:S:2AC1•ro~*~,u.[.rcaat
~ ;as5 .Tune 6, 1974
VR 200 (1971 r) Toots Depart ent of PubL'e Health -Office of Yltal itecoras b~iiv O~ t9:+. u.; 5*wv_.,:J Ci::ot~!~E~
I HEREBY CERTIFX.that.~he foregoing is a true and correct c ".lif`the death record
for the deced t ` '
arced ~ ,
et? .-tI ~at ZteJn. 1 and that this record w s '
_ a C lishe and filed in
~ d
Toy office in aaco>rdance with'. the provisions of the Ills
~tatl<i,tas;,Y~lating to
the registrars n of b rths t111births and deaths, f'
DATED , _ ~ f SIG::ED ' e~ ~I.d~~`~. E
~I --~'r•~~yy.~~ . ' ; ~ , ~ ,,.E
AT Lake Fof~~, ~•°Ili~'nois OFFICIAL TIT Lif' as}l~~"strar
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1980 OCt -7 os
502399
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