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HomeMy WebLinkAbout03721 514341 4 . ~ I ' ~~ ~ STATE OF MICHIGAN lF -- !y -- - --- -~ t . ~ ; t .: ; • <•,, ; ~ :;""~ DEPARTMENT OF PUBLIC HEALTl1 ~ ------- -- -- --~ ~'~t.-..~J ----- - --- --- ----- ( ~ STATE FILE PiUMBER ~1 .. ~.~'-:~n.~.i 0 0 6 9 3 7 3 B `~••~4....~~ CERTIFICATE OF DEATH ~OECfDENT NAV1E ~.xsr Y.•,l!nE ~-s~ S[X f a1TE Oc pEan. (I~,/o. pay Yi.J ~. ::eraldine uilliam __ ?_Fe~=ale __~st`ay_ 20,_ 1973___ _ _RACE .~•y v~.e.. s.w~ .~ - AG~ i.i e.rmr __UTtUER 1 VEAR_ U4DER 1 QA~_ 0.1iE OF BIR(N (M.o.O~y. )i./ iGOUNTY Oi UE~SN wr, «c~ ISL~~rYI /Yn.l iaos (-owrs tiou+s~-irwa • ',r'hi te - --- -5a~~-- -~-- s°. _---1 - 5c---l--- 6 _July_ $~ 192t~___ I ~~ _ :':a~rr_.e-- IOCATqNOfOEA7H ;~,~~nt~~~,~s~ Lincoln Fark ~~WTAIOHOTNERiNST1iUTiOq-wr.+u:o-•.,.•:•.+.~...~r•..r,-r~>.+e«~ rcn~~ a:. i andsv~~hl ~.vsotw~+~ct~w~iso~ ( Lynn KOSpital 70. ~ r~n- o~ ~ 7c • • S~NE Cti W1N ~:1.+~.: ~~S a ~yi~2EN OF KNAi CW'IiRY ~'a4~:o ~.! rrn ~avnto. ~ SURV~\ING SPOUSE (/1 wile, give ma~tn ~+enlll NaS U'_CIDFNT E:~~ ~~ r~r.ycv.~-h: W4'1lMiG. U:V:IRCEO ~3~~n M US AhV~D iGA~FS' 6 OEATH ~ ~S.ra./ ~ ~ rr Iw~ ~~o~ s Tennesse 9 U. S. ~o i~:arried >> Ferr~r_ Gilliam ,~: f~o ~wsnrut4a. ---- -- ~ - -- - - - - ----- ~cF wMyu SQqAI SECI/RITY NU A9EN ' USUAL OCCUPATION (G~re Aind o/ ww~ done duiiny mas! o/ TKIND Of BUStYSS OR IN'~tJSTRY ~ -: -axxti,: wwk:~ Hh. eren iI irtwedl `•'"^"'°"`Ot „400-28-5897 ___!~~RQuse:vife ~.o. _~t home _ F=S:OiNCE IIFVS ~ cu~-n nLs~r~c~-sr~TC couniv ` iocnun -~ v.y~ pn ~w,r> ~ pllen YaI`k STRiET AtSD lIUMBfp lCneck one aod sP~~Y! ~ r`voE vwl~4r te~r~ts os ~s~. t=ichi~an ~se ~Yavne ~k ^~+~ a ~sa 1702'] Anne fATNER-NAME ~:asr wx~t -~Sr MOTHER-MAIOEN NAMf ~utst v~UO;[ us* ~e Alva tishleY ~~~. t~;allie Arrr:s INFORGANT '/ / "~ ~.- MAIUNG ADORESS S~REEi p1 ~ro wo Gr~ W tor.ti S~wTE N con.,,,... - ~i ~,u,,, 18a./S.gnature/ -f .ti ~..~/ , -~~ ~cc~-~^ ~eo 1702~ Anne. Allen ~ark ,`•:ich. 48101~ ~.~ ~,~ As~ To /~ 9 IMlr1E0U-TE USE /fNTER ONLY ON£ CAUSf PFR L/Nf fOR (al. !D), AND /e). /= ~ rx+.r ur..r. ~-s« .+s o.r.+ n+vt/wrE PART 1 ~ ~ /,~~ I C~u6[ ~iI J ~~wA . n.J~r _ ~ 1 ~.s S~A111~ iN( _ u"Of"-r~"+G pUE TO. OH AS A CONSE~UENCE OF: ~~~+- ~ O I-+t«.ai . or..t.+e ~+.c+ CAVSf IASf. ~ ! l~1 1 DUE 70. OR AS A CONSEQUEI~CE OF: ~ r.w ~ee.w r+« a.r e.,e~ ~ k, i PMT 11 OTMER S:GNtFICANT CONDITiONS- t.~w~twn cws.v.q ~o t~at~ e.t .e~t ne~~a u c~.a• s~•• +-Mt ~ AUTOPSY /Spee~ly Yes ~ WAS CAS~ REFERAED TO ME01C111 Pb/ EX/1Mt• E ~I~Yas a No) •~ 20. ~ 21. ~ PtACE OF DEATH Na~*c. tr.n.q wy... ' F HOSP. OR WST.. ~.x ww. p4a. ~ ~ ~~~~t ~ ~ ~ ~~ ~ ~~~ ,~ , ~ y ins u++ ! W ae~ • x w • .w~Ka esw \ 22i A'~' ~ %~(~/ _ 22b. /~.f ~~h~/ / C/7 / ` ~ ~/~ ~~~ ~~~~ r,. D O+ u~ d e m. r...e.: ~ e..~ ew~ aM+ wcvwe M n~ / Z~. ii - t~Y Ot n/ Ww!WpR afr ccv~~A ! s'\1 NY.! >! be Ia Mrti Wte a'y {iKR M1 i.e iJ iV Cay1111 YMd ~C.KSt.1~ itf2ld t . p Z /$qnafure ar.d Atle) ` ' ~~~-'~ _~~ Q ~Srgaatuie and Titkl ~ ~ ~ DATE SIGNEO /Mo., Osr H R OEAT v z DATE SIGNED /Mo., Da~; Yi./ HOUR OF OfATH ~ ~ _- ---23b. .~ , ~ ~ ~' 23c .~ . ~~~ M ~ a 24b 24c M V O NAME O~ ATfEN:11NG YSIqAN If OSHER TNAN CERTIFIER /Ty~ piA~nt/ ~ W PRONOUNCED DEAD /Mo.. Day. Yr_/ PRONOUt:~EO DEa~ /Hov~~ 23d. ' 2dd ON 2te. AT M NAME AHU ADDRESS OF GERTIFIER ~n~rsr_~•lYOR ViD~C4l ExIW?`~fMi /Typld PYY1(/ ~ 25. ~ x:.c. su~ooF- No'- ~..~TUaai QATE Of IVJURY //da. Oay, Yi.) FiOUA Of INJURY ~ESCR~BE FiOW WJUHY OOCUHRfO ~ on rErrwr ~wESt 5-:..•, ~ 26a. ~ ~__ 26D. 26c 28d NJU A WORK PIACE OF INJURY-we r~r.~.. am.. w.a. r.avr a+e. tOCAT10N Sf11EfT q111iD ~.o orr. v~uet. on roww~r Srwrc f (SPec~h Yes w AbJ n~+e~4 +rc /SP~u~YI ~ 26e- 261. 26g. BURlA~ CREMATIpN. REMOVAI. OTHER /Specily/ CEMEfERY OR UiEMATORY-NAtAE LOCA710!1 or+. vwu~_ os towws~v StwrE ~ ?>> Cremati~ 2m :~ood~-ere z~~. Detroit, A`.~chi~an ~ ~ DATE /Mo., Dsy, Yi.) NAME OF iAGLITY ADDAESS OF FAdIITY 2~e. t~. ~97~ Ze~ :i.r. Hackett h Son 2eb 2640 i~onroe, Jearborn.i:i. 8-36b fUFiEHAL ^ CE IICENSEE /~ i ISTRAR r ~ DATE RECEIVEO BY REGtSTRAR (/ ., Dsy, I1/781 /S~9 xum /`~ . / ~ ~( ~~~ ~ ~/~ ~f~ i1 ~ \2ec ~ ~ _ / /i1197 /. / f ~an~1~y 1 ~ ~l~~l~•~ilvL/ 1294Ge' GL~" /// ~ _._._~___ .___~ . ---~ ----- --~------ --------__..__. _~__ _,._._-----___----~, i $ S'I'ATL•' Or MICHIGAN ~ = COtJN'PY OF WAYIdr. ~ C ITY OF LINCOLN P'aRK ~ ~ I, Irene :B. B~rta? . City Cierk of zha City o~ Lincoln P~.:rk in s~id County and ~ State, do.~r~by certify that the above is a true copy of a Certificate of ` Death:=on fi~le in the office of the City Clerk of the City of Lincoln Park. ~ ! • '. i.' In witness whereof I have hereunto set my hand . • l ~ ; ?~ `~,~' _ and have caused the Corporate seal of the City - ~ ~_ ~ of Lincoln Park to be hereunto affixed this, ~ . . ~ w _ . ~ai ~~~ 20. ~ 2~ 3s 5~4341 ~.. . .. . : . ,. ~ ~ . _ •. .''. f fILfO Rne Ff L'OR;ii a /~~~`''/ - . ST.WCtf CWINTY.FtA ~ ~•~ ~E'j ~ ~ ~ " ROGER POITRaS - CtERK CIPCUiT ~QUFD1 $. BARTAL - CITY CLERK '~! " ~ ++ff.`'R• \•;F~. . `~( . ~ ~~K ~ ~ $o~ 34? P~~ 37~ ~ z ~ _ .~ -'`" '°.-.~~~, ~-- - - . ~~~`