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#85967 (1965) CERTIlIED COPY OF A DEATH RECORD
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FICL IN WI1N 1YIEWRIIER OR [EGIAIE IRINi)NG
STATE OF ILLINOIS STATE FItE
NUtA{ER
oecEOENT s MEDICAL CERTIFICATE OF OEATN REGISTRATION REGISTERED
{IRTN NO. OISTRICi NO 60 e 2 NUM{Ef 78
I. !'LACE OF DEA1H
• STATE
D COUNTY 2. USUAL RESIDENCE iwM•. oe<weed ed Ir •ntr~r„r•on. .e.•denu N+ore
s STATE D. COUNTY odT•rt~on )
lulNOls Madison Illinois 1 Madison
c. ^ INSIDE corpwore Lm;l: o.•+d .n C;ly. V:COge, or Incorporoled To.n c. ^ INSIDE co"cw"ole t,m:rs and :n C;/y. Vd)o9e. w Incorpyor,d 1o.n
d. 'OUTSIDE capwore h +n
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~xn°"~ak . ;NNGT` Oc STA d. Qs OUTSIDE corpo<vre t~'~ri "`Dak e. ~i 2- o~ i~ eESIDENCE
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Rood D;ilnd No ...................... 4 rS Rood D;srr;N No...... ... .. - .... 4 rs e
I t. NAME OF HOSPITAL OR INSTITUTION T q tEN.,t-t OF STA
IN :+ t RESIDENCE ADDRESS f1+.ee+ 6 No or R F 0 and /'osr Once)
R RFD #3, Box 263
~ H not ~~ hosp let w •+tt•t„t~on. q .e SNCN i No. o~ R F.p. and Post Oq~ce
RFD #3, Box 263 a. D:d decedent re:.de ON A tARY' YES ~] NO
tlt
t
i
). NAME OF a. I
; ~_ It~IDDtEI c ttASrl 4. DATE OF !IdONTH; IDAVt NEAR.
DECEASED WILLIAM D. LONG DEATH April 25, 1965
5. SEX 6 RACE 7 MARRIED NEVER MARRIED 8 GATE CIF fiIRT-•! 9 AGE ,.n reors '' ~ndeo r rp. .+.,nder l~ tit
EMale
White WIDOWED DIVORCED (spet;l y) ~o:+D•rrhdor) rotirre e..e ..ou.e r....
2-18-1905 60
IOa. USUAL OCCUPATION IOb.KINDOFBUSINESSORINDUSTRY _
II. BIRTHPLACE (Cdy o~d wore or lo•e:gn co.n+ry) 12 C'~".tenoi rh0+
~ ~ Machinist
~ G. C. Eng. Depot Pilot Grove, Mo. `°~"rry~1SA
I
3. FATHER S Wll Is. MOTHER S FUII
NAbtE
- John H. Long MAIDEN NAME
Clara Friess
,! ° 5 W'o:_oecrose~ e.er ~~ U. S Ar,.~ed Fo•ces~ 16 SOCIAL SECURITY 17 INFORMANT
'. "ee. ^~ - +^•ra•~, ~G•.e.o. a d~ai o, .«..:.: NUMBER s SIGNAT -E
Mabel Long
'
_
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334-22-0981 ~ ADDRESS RFD #3, Box 263 c REIAT!ONSHIC TO
_
- DECEASED
' Ie MEDICAL CAUSE CF DEATH Edwardsville, Illinois Wife
DART ! OEA'r+ wAS CAUSED {r. (fnrrr on:r ow ;o.u oe. •~. to• r Al t{1 and {Ci 1
INTERVAL {ETWE~N
~. nrt4EDtATE CAUSE IA'. ONSET ANp DEATH
Acute Coronary Occlusion
;, _ _ _
' ~ Mlxiutes
_ ..
Condd.ons. ;f onr.
.h~ch q°re rte ro e.e ro 1 {`
'~ rheoborelMMEDIATE Coronary Artery Disease Years
CAUSE IAA srer,ng _..- _ _.. .. .
the UNDERLYING aye +~ tCr
cese ~ecl. Coronary Arteriosclerosis Years
DAfT a OCHER yGNIR(,ANT COND;T~ONS CONTRI{UtING TO DEATH {UT NOT RELATED t0 THE TERMINAL COND~T~ON 0 AUTO"SY~
SIVEN IN DART I!AI
owt[ or o-[w.v:or
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e.
.lgb .n.o. •~ne.uc. or o~r.~rur
NOTE: if an injury rat invol..d in E6
is
deatti, the Coroner must be notiFiad.
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21. ~ - hereby ccrr.iy fhOf / oaMded M! dKeosed /io+w _ A rl _ _ 1 v_,[ S? ro . _~-? 4- _ . 19 6 5
-hot llotr tor. the deceosed olne
,
on 4- 2 5- l9
2
P
6 5
d
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an
deWh Occurred er
_
- - - M Iron Me touter and on Me dme ero+ed oEore
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Garf 1.: 'wi~1 I KEnSe
s .~~d+~re- .Melvin J.- Freedman.... - ... M.D. 1•ar~ -- -- No. 32021
Address 1255. Niedringhaus,..Gronite City,..111. Pi one GL 2-2144
2?. pISDOSIiIpN EIURIAI _ Oele 4-27-63 2I. FUNERAL DIRECTOR -_-_ -- ---- -
SIGMA?URE - Robert G. Thomas
CE-~FTERY NeW- .Lebanon.. Celt-eteacy... - .
ADDRESS Granite City
;' , ,cAT,oN Brunceton, Missouri
Il~.x~ois N°. 4199
'~ `''~g ° Aril 26, 1965
~: P
Alvin E. Wooldridge,
_______ --_-_- - _
_ locAl REGISTRAR
I ifERt
end tlt~
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~iegoing is o true and correct copy o/ the deoth record For the decedent named at item 3,
ed c++d Tiled in my oFlice in accordonc~ with the provisions of the Illinois stotules.
~'~~;. /
~.. Via...-~_
~ ' ~. % SICNED~~ ~
'--'-~r----------- - --- ~-
~`=~~ Co Clerk
~, Illinois. O IAL Tl~~--
~t17 Hied with the ILLINOIS DSP E OF at dnntlfeid. Cou"n~r~le~
ie~ from erDlee of the oritinal record. 7'he nds etatutee prari that the eerUfieation of a da reeo y the
+14ttietrar or the county clerk shall ke Dr facie eridenca in rrb and Dlacw of the facia Cher elated.
BUREAU OF STATISTICS - tLLIN015 OE 'ARTMENT OF PUBLIC HEALTH - SPRINGFIE
509840
8344 Fa~E1689
190 QFC -9 P» ~ 16
FI«c 1-r.c F~coKnru
5 NOGER POI i RASA
CLERi(CIRCUIT COU T~