Loading...
HomeMy WebLinkAbout2272 i . /~r~-~ _ .., _ -.--~.•.,,.:,.. _. _ -. . . ,.~~~".. ~- -~.~~ 513690 NORTII CARC1l.IWA Of:PA{iTMEN7 OF HUMAN RESOUFiCfS!'" "''-'j" ~ Re9~slratlo~?G OU DIVI.°,ION OF IIEALTH SEHViCES - VIIAL fiECORI)S BRANCH ~ . o-t.~ct rao.___Loca~ t~o_ CERTIFICATE OF DEATN `~ l ynr, or p~:nt In pcrmanent D~a~k Ink r . . . ~ , PART 1. OEATH CAUSEO BV: ENTER ONLV ONE CAUSE PER LINE Name ol L~e~ease0 ~.•++ •r~•»~e i.,~ ~e+ UJl! ol Ue~ln ~~uo~•n, Wr. ~~~.1 ~ TI~EL~lA L0~°JIIi~E FREE:"~kN FEILALE AUGUSI' 1~ 1°80 ? ,. Golo~ ur ate 51a1e ol fiuth 1~~ oo~ County ol Uuth p Uate ot Uul1~ Aqs t~•. v.... ~: u.~a.. ~..s. n,,..ne. ~a r,o~,.~ U.S.w.. rre t~.uearl ~ ~•~~ U••~ne~•l Mo..tws Wrf -bun ~A.n. CAU I~ VI RGIialA Crcenhricr DEC 28 1904 75 S, . .. Sb_ 6. . ~. Vl~cc ol taltl- OuntY C11y o~ 1 Own Nanlt OI t~osoilal O~ Inil~tut~ull ~~ ••,•+o- o• ~•.s~ ~n ..w .., e.~.~~.. •.... u.e.~ ,..n .,.~..w..~ ieo i:~iq[ v.t ~e. wwt Ins1A! C~ly llmlts ~res .r~ hu~ a, CU•1E3ERlAND eD, FORT BRAGG s~_4:~1i~ACK ARtaY HOSPITAL sa. ' e~. ' Hsf OlMe - Slat• Counly C~ty Or own Sl~eel anA NumDe~ o~ R.F.U. 6 Box N0. Ins~dt C~ty ' . l.IT11i1 te~ .N Mul a~. N.C. 9n. CUMBERLAND ~. FAYETTEVILLE 9a. 1425 V~.. id IA ~- Cit~itn o1 Whri Counl~y. w Q~eO, Olvo~te0 (50lC~ly) S"rrlr~nq SDOuu (11 W~It, 4~ve Ma~den Nam!) io. U.S.A. ~i. MARRIEO is. FRED A. FREEt~1At~ - HUSBAI~D Sotlal 5ltu~Ny NumDer Vsual OetuDal~on'~~'^ou~ «u•~ ow~e e~•~:y .•. .~ w~.r~. e.en .~ .aueel K~nO O~ Hus~neSS or InOutlry w~toeceww~ F•e. •n V.S. w.n.es s o.ces•I~'s m Nol 1324G-10-940~ ,4,. NOUSEWIFE ~•o_ t1A ,s. NO - F ~t~er's Namt Motne~'i M~~Oen Namc tIARD VALLA~VDINGHAh1 -DECEASED FlAO:tI MJ~ROE - DECEASED 16. ,,. Inlo~mant's Name an0 AAOresf Rel~l~on to UetNted ~ZEL VALL/1i~lDIi~GW'1i~1 1~413 BRIARCLIFF ORIYE FAYETTEVILLE ~~~ C SISTER-Ii~-LAt~! , , . . ia,. ~eo Condltfons, i~ any wn:co qa~~ .:.~ ~.. Immeewte cause /a), ......_ lylr-g csuse us4 t,~ ,mm~,,,.,. ~,,,u, CARDIAC ARREST ~o- o~e eo. o~ ~s ~~o~:~o~~~~ o+: AP~TERR IOR LATERAL i~IYOCARDIAL I i~FARCT I ~ ~~.• - •.. Sy~ wltD per- manent blatk Ink. l9. (c) Due to, w as a consequence ot: PARrt 11. Ot~er Siqnlflcant Conditfons Co~triDutlr.y to Oqt~ Dut not relstcd to cauxs qlven In Part 1(a). 20a. A~~oD+Y' ~~ 7K ~e~e ~.M.nq~ c~sbe.iO.w Ot~e•m.n~r.~ cwK o~ A~~ln Was cax reierreO to MsAlu~ E:am~ne~ ~~e~ w~+o~ TiT! OI Ol1lh (vef w No~ so~. P~O 20~ NA 2 i. NO Zz. 2: 20 P. M. NOTICE: STATE I.AW REQUIRES THAT ALL OEATHS DUE TO TiiAUMA, ACCIOENT, NOMICIDE, SUICIDE, OR UNDER SUSPICIOUS, VNUSUAL, OR UNNAT.URAL CIRCUMSTANCES BE REPORTEO TO, AND CERTIFIEO BY A MEDICAI. LXAMINER ON A MEOfCAL EX- AMINER'S CERTIFICATE OF DEATN. ANV DEA7H5 FALI.ING INIU THESE CATEGORIES IS WITHIN THE MEu1GAL EXAMINEft'S !URISOICTION REGAROLE55 C~F 7-IE~ENGTH OF SVRVIVAL FOLLOWING THE UtVDERLVING INJURV. Nime anO T~t1e OI Certll~er (1 ype w PNnt) AddreSi ~ 2,,. BYRON R. RAYSOR ~ CPT. ,hiC. 23o.WA~IACK A~ ~ 519^+iut~ ot Cdt~l~lr~~ ~i Dale 51qneO ~ -- "~-''~Ir -~~'_ /~ • /~~-CI,OC~L . 23dAVi7US 1 1~ l A~A LOCaU00IC.~~. 1o~n a Couwql Bur~_Cremation, Utne- Date V Name o/ C~m~tery p Grematqy IS t.l~l . ' ~~;urial_ , 2.,. 5-20-8 2.~~.afati•ettc '~t m !' ""°' :ttq~Ters ; "i:'~eecc FunL~',tl Hor~e 51gn"" ~ zF.n. i3ox 135 I~avetteville :.. -26. ONS 1872 Oate Rtt'd by Local Rt¢ 5~ alJrC O~ ti rar ~ S~ natu R~E V~7/~9 27a. ~- ~~- O v 27~. /~~%"1~~• ~i~~l'^"'vi~J i~ i~ 1981 .ll,tr 15 A'~ 9~ 36 : +l ! C ~hi F~ CORGf . , ~RO ER POI~T~AS, CLERK Ci~?Ct'IT CCU~j~ ~f~n4n•;'i ~ ~' _ ~'o - ' S~ 3690 une~a~ O~rector l~ ~ ~~ ~ ~~~i.. .,,f~.-. ~~ ~t;,1t::)~'~ -d.~T ~I~ "~'rue c~n•• ,;i ~ ~~.~.~~~t~;ec; j~i..~c - ~ _ ~,Jt:l,iL•7-?.~r:~i r'J:.L'~Y. ~~''.it t.~t.;)~t:;i.. _~}~ • `~ Ai '!'i~is~,l/ cS ~1r~.-:.{ C E. . • ~~'a 6;it';:. ,- ••~, ~ ~,f'/y,,;z,~•.',~c' . ,.. .~, _ . .• ~ • . !~•~, _ .: ~ , .~;i,:;» „„ - ..~;:ii.i^fl..~.. ' .~}/~,.. -------- ---.._~.:,,,.- 1'(i` ; ~~.,.• {3~ ~'~; ~T ,,, t~~ / , w - _ . /~i}I.~! ~ tsy 'Y~. ~l y -ti ~ - ~ `~ ~~": ' !-~ I~ `- :~ • ~ ~' L t t~ J ;~ ~~.Lf ;.~~ f ~.~~ ~ ~.v - ~~ ~:. - ~ 7 : ~ • . _ l'..~ ~ I ' ~~Q : B0~1K~~6 PA6E~~~.W i - - -.- - .~~ _~ •t+-Nw Owf~t lnA W~ 6 DAYS