Loading...
HomeMy WebLinkAbout0654 i SU58'7'7 OHIO DEPARTMENT OF ' ~AL.TH I DIVISION OF VITAL ST FIGS ?r..•rr lt)U•u hn sZ2.Q~__ CERTt FICATE OF DEATH Ra«,,.«-, /r+ -~5 _ _ Utf.EDrhl "4:.VF Fun 4.JJU L:•r '+fX UAfE OF OFAfR rtr,-1•a,, lu•. CFiLiQ~'IS DAVIS , gale Sept. 6 ~ 1979 R:.CE -hq.-Wn,tr•S act•A•rva.~ L1'vE-tau TWtWar U_•JeR 1 Yi Add U`d•EH 1 UAY DATE OF bLITN /Vo.,l4?. Fi / TCOVNTY OF OEATM • +M Iwe•a•a rK I lt,•YaY lrv+• - - / 4I~•, 1 Uarl Nour1 1 4.M. ~ ~ _ ;white - - `S._ _71-- - s, _ s<. Jul' 30 ~ 1908 Montgomery - CITY•\:ll•\uE INT LOCATION OF JeATN NOYITAI OR OT/,fR INSfIT4T10N-\+r•v if/worinnM•..rwrwe+u..IrwPrU Tr-^t•Sr UNI\ST. 1•~: <ae. DOa, ~r.° =_w•r FI•n : rprt rrt ~ Wr•h. >>e_x _L_ebanon___ _ ,x.__120 :S. Main Street _ --1„ STATE OF TIIRTR IfJ w.y rw 1 SA., wr+r 'CITI[EN OF VYNAT t:pUATRY ORIGIN 4R DESCENT R;y.aw. Wa,iy/, (.ewn.n, Engl•A. CuOaw, SOCIAL StCUlrlir `avMHER cer.rr•1 TLrto Rean..s-1 1SJeellrr ~ Ohio _ _ _ USA . Aaer_ic_an _ To ____~Ol 07 4602 i waS DECEASED EVER r.FUS. wTU1FE0 eCIRGES+ MARRIED, vtvEw MAwaIEO. rSUpvWIN4S?OI;iE Lq..ye. jr..r..r....+.r I Yrt n•., or r+l+o..+ ll! rr. r.r Jrur y+•+,+rr/ WIDOWED. DIVORCED /JiaN+rr Tl f es _~Q~~-11~~_ l~.r,arzied Iljp _ _ Dorothy Martin_ USU4l000IWAT1pNIGf.+Er.r/e/~+rt Jswr ad.aT, wort v/•we•try y.. r+rwi/reK«d+ KINDO~6USINESS OR INOUSTRr r~~ Ox~er _ r:~ Dairy Queen RiSIDEhCE-STATE ~COUNT,I CITY. VILLAGE OR LOCATION STRFET AND NUVhER ~ /hSIOF CITY ll V17'S ~+•31ont ome T.c. hex Lebanon ,.e rsM~,rrrw..wr I I•a Ohio 120 A . rain Street Ta. Yes FA TIaeR-have lutr .tltl•fN Lary ,MOTHER-Y.aIOEN NAVE F.nr .rrL~Yr L.rn • ~ rs Jerkin J. Davis Elizabeth wood hFORV 1hI-ti•ati,f llFN IGIAIUNG AO:J•+c_SS tSTR_ET ORRIO No.l ICITV OR TOWNI uT~TE1 'La! • ,~Doroth Davis ?T,. 1203 W. Main atreet Nex Labai~on Ohio 4534 AoearJ.t•VA:e :r.rawvA~ • vaaT 1 _ DEATH WAS CAUSED BY: [fNT[R ONL Y ONE CAUS£ °FR LINE FOR /al. lbl, AND kl[ TiF rnr_v ONSFT wvu oeA. v _ 19 - i IMMEOIATECAUSE lal Acut9 %:?yocardial Infa_rctio_n OtiF TO.OR Aa ACONSrOUENCE OF~ ! I Cerebral Arteriosclerosis fi:r Ir+r h• t•!^,n1Yfr f!1 • truer. Gran+t f>rr rnJtr_ OUE TO.OR a5 A CONSEDUehCE 6i _ H ertension_ _ _ _ _ _ 1.1 YP _ ?ART II. OTRER SIGNIFICANT CQ.YOITtONSCwdtMe+..enrMrwe=+n•JHM.rr were .e4rwf ro<~;w Frw+u. PSr[/ar AUTO?Sr NAS CAST R}FERR_O 1D C:aih2R - I/'n ar +y I•TMI/) 1"n a ~"f _C'nron_i_c Con$est~ve Keart_Failure _ s,~.. No T9e ~ ACC.SUICIDc_. /1'JV.,UNOE f., IUATE O'/h1URY HOUR- - 'M 111rUq,'000URREDIfwrrrrasrr al.r•+)~aFMIa•?aw ll rtw+tr! OR F'EVOING WVFST. /SNrr/ir ~lY.•.ri. Ur). Yarl /+A IrT•r /.r Nrry. ~.rlK? rL7_ATIC/h /Sr•rrr~.•Af.fr wu. tn. o••.Ilarr. rMr. +rsr /LJaaY AT YYORR PLACE OF IYIURY Af rrow,r, r--~ fCNnll rr+.••w.v +:Jr. rK. rtir'rrllr ?Or '2r11 I To tee T:owITlleTd by ATTENDING PHYSICIAN Only To be tarllplettld Dr CQROFIER Onlr I 77 • Tu tw+r or •nr wnrw.~eCrrl•,ua7. ar1..YW N ,n aat. aM px. ow •o •n -.uuRi 7: I Ow ••e a.F, ol.as.wr.on aM~w ....ear.ytwn. .n m? op..w. rev. ~.cu...v al ^v [a•••• Ow. : a•arM l !f//J'- J ~ ?~1 o•+ce anO Ow :o rr u •rlll IutM ~'I 1SrF+ss•r awJ Anr•_ ' (~V'~i/ I/ v r a-a_.•+• :+J T.tlai {tI ---"""___TTT -7 DAi: SIGNED •tt?. ;arJ• lr» Ir•GUa OF OSAT.r - -7E StGvcU r+l+.•W?, Y'rr._--TR(kLR OF pEATN i .~O•.Ut.Y ?D DFAD!w.n+?. 1"na ii ?F+9ti0U+I:ED DE37 •w.•rF _ r j i ~ fa:.YC A1.O A: G72>S Ui i,en:.-. e.l irr/e9•~•..V G•~ CC:?u~\en• I:rpr .+I~ar. y:•rrr ~+Y F L a , nr, u• n:Cfrr rrrtr. :.-J r:alcol:n Block ~~.17.. 64U ridelit ~ld~. Dayton, Ohio 454G2 N'J r.IAI.CREVAfI.1N,~0ATr ~NASIe JF C[VETERr Uri CR_VATORY 'L:1:A(IJY rt,r. •.::aN, o•: w+rr/ ISrs!•. f ~ ~ oT.._a:SJrr~;.•__ _ _ , Rio Cranda _ _ _ _ f 2.. Burial'.~e~t. 8,1979 `.Calvary Cemetery -----~j,b - ~ uhio----- N4ti,? OF E••'dAlIJ1FR It IC No 1 AAl rJIRECTr,R'S SIC ATURF _ Il•-. ho 1 n __Jay A. Soot ?401A _~nw_r~ --L~•-~_ "~Gy: ____43~ FuVcRAL FF'iM ANU ADDRESS ISTRFET NOJ • ICrTYI / ISTATEI IZIF'1 zf____-R°7ers & HOB ~ a 324_~~.._t'' S_t. _._----t_ie_x Leba~l~_-- thin LK~~___i - - ate- ,a~_ r ATE fiDCD B~ RgGISTAA 31RF~. . ~ ' DaTE v- ~a I ~ iSUEO ~SttihAiuwp OF vFRSOh ISSLIN(: if RVIT DI .roe. I hate E`~t~if ' ~ ate. by y~ a true and complete photographic i reproduc ' rho } j~~-~:, on file in the Department of Health, ; Dayton,;, b'. t ~ ,.I t ~ a ~ , ``r,. ~ t Date f Loc :icgistrar _ s I ; F Fee: $2.00 i I ! f B( K PACE ~ ; ~