Loading...
HomeMy WebLinkAbout1364 51.3132 . ~ eo~wlv/NM ~ • ...~..~~ . _ ~~ CEMSNS W- , _TNACi - O~YIi10M 11lOOAO~OqTMC~ yl~ NEW YOHK STATE IlEG~3 ERNYM~E11 DEPARTMENT OF HEALTH _ ~~~ CERTIFICATE OF DEATH L _ J i~.~1~Si~KpSTq~CT ~ ~ 1.NAYE fIq3T WOW.i tAii ? SEI[ y- pATE0~0lAiN '~B NOUR ~ REC Y1LLE fEYAIE y~MiN ~ OAr ~ tEUI ~ --- ANDR~W BAfIItY ~ O 2~~ 1; 78 ~ ~ RES ~ ApE ~F UNOER ~ ~EAR ' If UNOEN ~ OAY ~S OECEOENt OpRN • YfiEiuN Os U S wq~EOfOACES~ 1 SOtu~ SEtV1~~fY -- NU40ER _- ypN1M! W~3 ~ MOYA~ ' w~Mllf! ~ YOMM~ OA'I ~ tiEM ~ rE^$ li 11E3. S~EC~Fr N1M OA OATE~ ~~~_ ~r` ^' 60 ; ~ ; ~ 8 ~ 3~ i? ~ SERY~CE ~~ v ~.~s ~l- CWNTY Of OEATN '~0 IOCAl1TY(GNECK p11E ANO SYECIir1 •~C MOShTK 0~1 OMFN ~NSTITYl1pN " W~F'M N03h141 O~i "~E ~F IN~A~EN ~ 8~ F- ~ ~ u(~F iNEa~fNE0. WvE AoOwES31 ~ u+SUiUiqN ~CMfCK ONE1 ~ wD~~SSWN OniE ~~ W Nassau ~~ppyp~p~ Oyster Bay ~ rii~.l_Island ~s~E Et1GENCYROON ~~TM ~r vEw11 0 ~ ~ ~~OQUi-ATIENT ~ ~ 1 W ~ ^~..~E~Bethpage . ; Hospital ~~~tNVATENT ~ ~ ~ W/. STATE OF B~RTN /0 C~T~ZEN W NMAT f 1 MAq1iAl5TATY3ICMECK ONEI tt SURV~WNG S~OVSE l~ M11f E 41~IE MMOfN MAME1 Q ~COUf~TRY1FNpTVS1-) COUMTRrf ~ONEVERYAR111E0 ~QYNDOWEO 9 New York USA :~~~~~x~rowc•o~ ..EO Virginia Hawell 1, RACE MIMITE.BIACR ~~ ~'S~AD~~SMOp~6~M7 YES O~NO ~S EOUCATqN IN0ICATEMI6NESTOMOECOMRFfE00Nlr • AYEN~CANINpAN. 1FVESCNECRONE ~ E~FYEMTMIr NqM$CI~OOt ppl~EpE 1 3 OiHER (SPECtFY) t Q YE7UC11N ~ Q OtMER 5-NNSM 20PVERiOR~CAN ON~O~MIS~EGfVI O / 2 ~ • • • 7 • • t ~ T• ~ ! i • •• y~{~ ~~ CU9Ali ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ ^ OO ^ ^ ^ 0 ^ Rllite •QCENTRACON pp O~ O= 00 M O6 O~ OI p~ pY t0 t1 It 1~ 1• ~! 1~ 1) SOUM AYEN~CAN 1 4 16A USUAI OCCU~AiqN (DO NO~ ENTER RETIRE01 11la KiNO pi 6USU~E3S OR INDY3Tqr ~ IeC. NAME ANO IOCAl1fY Of FIRY 011 COYYANr ~ 1 ~~ Management ~ Aircraft ; Grumman. Beth~a~e N.Y. ~ / 1 lA SfATE ~ 178. COUNTY j 17C IOCAUIY tGNECK ONE Al10 6rEGt~Y) ~~ sE V frtv ON VilU10E. t8 RES~O~NCE ~ 1MiNINp1110A V~LLAOE UYrtl7 ~ ~ ~~ ~ usw~aES~o~ W New York ~_ Nassau ~~ ~ a S~ ~' ' ~ 0 7fl ~•p.~-T~-.: wW~aFKr.crw~rr__ •-------------y- ----------------t_ ~~C~'-~~3~~5------+ ~ t 70. STNEEi M10 NUYSER Of RES~OENCE I~NCLUDE 2V COOEI ~ ~ ~ ' Oyster Ba '~ 3 Rhonda Terrace ~ ~ s~wsr ~~ooae t~sr ~~se Fwsr ~~owE usT ~ u ~ " 'E°` Theodore Bahry ;~" ~ Theresa FATNEN~ MOTNER' ~ ~ ~YANwYEOFWiORYAMT ~l9BYAll1MOA00RFSSt1NCWOEZIPCOOEI , 11735 ~ r, Vir~inia Bahr,v ~'~ Rhonda~ Terr~~e S. Farmin~daleNY Q ~ ~ 70A eUR1Al CREYATION. pEYOVAL Op ~ yOMfM ~ DA1I hEAR' 20B PIACE OF BUPIAL CqF Wf10N, REYOVAL Op 20C IOCAT1pN (GTY OR TOMN. AiEI U ~ OTNER WiOSIT10f1(SPF.CIfr) ; , }-~ OTHER O~SPOSITION ~ ~~-~~' Burial ; 2 ~5 ;'j8; Hol~ RqQd Cemetery _~ Westbur~v~ New YQ~ ~~ ' 21A NAME ANO A0011ES$ Oi FUNERAI NOwE FaI~ • ~ ~ t1B RE615TpAilON Np ~ o•~~- Arthur F. White Fune ral Home, Inc. , 315 Conklin Street, ; _ ~ . [] +~ t, t7A NAME Of FUNERK 01NECTOq ~'129- TVRE OF iYNE EGTON ~ 21t. REG13f Np Cl ~ ~i .~ V Q~ t~ Robert A. White ~- ... ... ........... ........ .W . .. ' .._......._~ 0601~ ~~ ~ ~ /'~ /~j,y,/ /~ , RYtT 1 2~8. YOYiM OA1/ I rEAN. S~ O • L~ ~~ ~' ~~~IS i i I R V ~ ^ ~ DqtE L~OMiH DAY tU- BURULL OR HEYOY ' f ' _ R1 1.~ ~a O~i N ~ :~laiai~, ~ F~LEO ; 1 , `i ~~1 ~ 1 ~ ' ~ ..., . .................... ... . .. . .. .. . . . .~~ ~ . ~ ~ ,~~ ~ ~ ~ ~ ~ ~ ~~ p~~~;'~~{ ~ ~ TO BE COMPLETED BY " ~ _~R_ 5~~+' TO BE COMPLETED BV\ v~ v p~ n CERTIFYING PHYSICIAN ONLY =, ORO MEDICAL EXAMINEp`QNLY .7y (~j ~ A TO TME BEST pF YY KNOINLEOQE OEATN OCCURPEO AT TNE A ON iNE N1 YINATION AND/OR INVESTIGqT1ON, ~~Eq~ ,i a . ~ TWE. OAIE ANO VIAtE ANO OUE ~O THE CIWSES STAiEO IM YV ORM ATM OCCURNEO Ai TME E OATE ~ ~ ~ ~ ~OwiN pw~ -Eww AND RACE E TO THE CAY S S~TyT~ ONER'S \ ' L~ .~ L~ ~ 1 S~G~p RE %%/ ~ p1G~l / . ~ ~ - ~// WER j.1 ~i 516MATllRE ................"'........."'......i......_.~......._.._....... . TITIE ........"_"""'..._.......... L/ ......'•""....._........~ ~ ~ ~'~ ~~ ~ LiNE~M~SIC1ANAnWDEDTHEOECEA5E0 ~C LASTSEfMK1VE B,.~ „~ ., iNCEOOEAD ~G MOUA • ID OATESIGNEO ~-.-1 O(~ '' _'- ~ wr tEA/l YOMTN wr rcww ~ rourM wr ruw ~rN wr rc~w ~ 1 roMrN wr • J l}~ ;t~-••- fROY' ~.~ .~'.T TU ~ ~ ~ ~ t ~ 2 ~2~~ 7S~ Ai6iO3 P• ~~ Z ~~75 'y-{ ~ !A "~' . . ~ . . . f . i . . 1J ' TJ Q~ ~,' ~•~ ~ p. NAYE l~F A PMrS~G1AN.IF O1HER TMAN CERT~f1EA E SMNATURE OF CORONER-S PMIISIGAN. IF OTHER TMAN C If~FR H ~ N ~'f' i ' '~~ .`- j, ~ ~ Q' Uf . y''' ' -- r:•, ~ ................................................................ . ~ ~ • , .............. .........••.............. (,) U~ (d F~ ~ ~ fENNO 3lOiCERi1f1ERlPMK~C~AM.CONOMER.YF01CAlF7[AY~NER.COppNER5oi1V5~C~~N.YE01GlO/RECTq1) / ~~~ z~;~,." ~`s~~' ~,Ykari O Castellon, M.D. P.O.BOX 160, East Meadow, New ~York, 11554 hPPiip[IYAfE INTERYI~ 'r} w'~ -.. QEATN W1-s CM/gE0 BY EliTER OMtY ONE CAY4E VER LINE FOR (AL (BL ANO (GI I SETWEEN ONSET ANO OEAM { +-, ~1 ~ r}~~ ~ 1 _ '; ~~T L Ip~yEOIATE CAUSE ,r, ~ ~4 ' • r { Pendinq_ toxicoloc~ical and ( - ~ ~ u ; QUE TO.OP A9 A CON9EOUENCE OF. - [ ~ ~ I ~ ~ ~ ~s~ microsconic examinations. ~ ~ ~ OUETO.OtiASAGONSEWENCEOF I fl ~ (tl ~ ~ PMT U OTHER SH'sN1FKANT CONd1~pN5 GOMpT~ONS COYiRIHUT~NG ip 7AA AUTOYSri ' ZeB IF 1/E3 wFRE fIND~NG9 COMS~OEREO W 29 WASCASE i1EFEANEO Q OEATH BUT NOT REtATED TO CAUSEG1vEM tN VARi 1 W ~ o,.~ ~ YQES MO ~ ~TEN~Yy~NING iNE G~USE O~ OEATM7 i0 CORONER Oq .+ .++ l61 ^ 1 1 ~p rES ? Q HO ,~E3 EXAY.IlNO ~ ~ ~ w 1 T ~ ~OR SVECIF1/1~ AtGDENT, MON~C~OE. '~09 DATE OL /NJURV ~]OC MWR Oi ;~DO. OESCHIOE NOW INJUM~ OCCURRED O ~ESTIGATqN ERMIMEO. VENMNO ~ ypNiM ~ O~r ~~Uw ~ ~V~ ~ ~ ~ ~+ ~ ~ ~ 1 1 N ~ 1 1 ~ Y.~ _,, 3 . _ ~ ~ .~ Q ~OE WJURY AT WONK7 ~ ~pi pU1CE OF INJURY H01~IE. ~]06 LOCAf10N (SipEEf ~ NO. Gi1/ OR VItLAGE_ iOM/N, COIiNTr.STATE/ . S-1 G) H tES NO ~ iALTOiIY.OFFICE BLOG. EfC. ~ . ~a L: D O ' ' "~~. v -.r ~ 1 ~ ~ ~ '~ . ~ ~ , 1{, ~~ U O ~ p w 513132 1961 JA'1 I 2 FI•: 3 t, 2 Fi! f f thC ~i Cl,h.:t" .' ST LUf~F !:OCV-Y.FI A. fi(1GER f'OI7fi.•'- ~ C~Eh~ Ci~.:~J~ i r~~;. ? ~ ~i. . . . ~ an~x 346 ~~GE 1360