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HomeMy WebLinkAbout101319a1 JAN 14 AN a 5~ -..- i .F.-~ a :•~• ' ~s r_ ~ . S1R 105;i1 _,•,.' ~c ~ ~S ~~ ' ~ ~s L • w FECL4?DS ~ .C.- . iL:l . ~:.,. ; : - ~:.. ! ~- .... • "' ` r ~ DISTRICT OF COLUMts~w +~ ? j ;; ;. ~; DEPARTMENT OF HUl1lAN RESOURCES . S14'736 d ~ase Re~+ , Jvo ;• irtifica~ ~~-.-~ -:~'~ CERTIFICATE OF DEATH 8 Q- 0 0 7 6 9 8 ,. ~_,..:. ; Ei;:: ~L; ' _ , , ~T 1 '~ fi'~ flLE DATt I~e j~/o. 1.N1Aat6 OF DEC811SED Fl~tt Mtddit lw~t ~. AATR ~fontA D~r Y~+- ~=b. Hour oI Ds~tl~ ~~~~~n ot ~s- (1~!v~ ot Mnt) ~ Or 1 9_80 !~: 0~, .m. H~~ - B~'~N DEwTw Nov.19 L S. SBX ~. COLOR OR RACS b. Ideres Muiied. Ma+iied. 6. DA7B OF dIRTH u T ~ . AGE /le yeon od ~ Il VnAee ~ H{~ ation should 0! Male White wtdo . Dhoreed: Speci[~ QCt• 8~ 1901 Wt S ey/ ~owlAa Doy~ Houit I~/fw. ;illy supplitd. d, rLACE OF DEATH tN ~Vuhin~tOD, D.C. ` 9. VSUAL RESIDEYC6 (Whsn dectared /Iued //lnrttl~tton, eraide~v N/W6 OF HOS!lTAL. HU8SING HO)rtE OR OTHER IASSTITUTiON a. STATE b. COUNTY ~tOi'~ ~~^~t~~ I (: D . --- ----- r ~~t ~oe u~ r~.n~~n~-. a~,e.~e aaaK~.~ ~ D Y ~ i O ;e, ,rto~~a ee :. cirY a( Sig E es oR H ~ Y ~ 4S01 Connecticut Avenue N.W. Washins~ton ~es p e w r i t t! d d. STRE~T ADDRESS (// nr-a~, /!vt lonti6ltl printed ~~ ~r ~ 4501 Connecticut Avenue N.W. ent type blact 10a. USUALOCCUlAT10N(Gioekindo/~oor4 lOh K1~IpOFBUSINESSOR 11. BISTHlLAC= 1l.CITIZEItOFWHATL'OtTNITRY' doot rin mo~! ol ~tns lih. sarn i tG+t 1 DUSTRY (3hM or jonl~n to~nM) ~ ~ • - ~ a en~ ~s.. rwa~eR~ xwar isa xoraeas xwinea~ Hwas a. .,.o ~~L~s Jacob Berman Celia Lena Tellim Ida J_ erm ; rrrti ficate be• I6. Ev~r Is U.l. i-SOCIALSECUItI7'YNQ I7~. INFORLANT RELATIONSH/P TO DECEASED 17D. ADDRESS StrNt pq Stal! ,e~ a permanent M1° ~O'~! ~o _70-?4S7 Ida J. BezmanT Wif~~~4501 Conn. Ave. NW Wash D1 ~ d record wlftu '~ '~'-T~~~ ~~~o 18. CAUSB OR DEATH: /Enftr on/r one aurt ptr Use (or (~~ (8). and (t). ) perly e=ecuted. =AAT I. DBATH WAS CAIISED BY: 1 Osset ~nd Deatb: n~wen~wrr esuss c.~ ce~sation reaDira+~.fon~ ; 5 anin ~ CondltfOnt. l~aeY. ) ~~~e eo :ub~nit a z~~~r vu ~ai'.`.~~~ DUE TO (p) met.a~static carcinoma ~ 1 yr ~ iificate of Dath O~~tM ~mderfytns~+aws _ ~ the Departmeat ~ DU6'I'd te) nrostatie Carcinom~ 1 ZQ ~~_ 4fu[nan Rr M lART Ii. O'I'HER SII;VIFICANT CONDITIONS`• contiibutin~ to deaU~ but oot 18a. AUTOlSY? 18D.itYa.Wtre TindinpConqdete~ rsiated w tbe terminal dtsea~e eoaditloe ~irea in part [(a) Y OR NO to Deternainin~ t6e Gaa~ ot Death' ~ rces within ~8 ~ O , ~ rs :cCter de~tl! H IF OPERATION WAS lERFORl1ED 40a. DATE OF OY6RATION 20b. COIVDITION FOR WHICH O~ERATIOl~t ~ O01rrLC[E ITELt3 20~ and 20b WAS PSBFORYED a v~ofat~on ot lavrs vf the Dia' t o[ Columbia. 'R'I~iLIEK :OSS OUT---- ~° ex ~~Tx[s ; ~ ( iSPITAL". W u '"~ 31~.Syeeitf d aeciden~w[cfA~.6omf• Zlh HOUR AND DAT6 OF INJURY: 1~1w-t6.Da~.Yeu =Ia DESCRISE 80W INii7RY OCCURRSD U eWe' or m~anu mdete~ind x• (~nter n~t~nr o1lnj~erY in !r-t I or Po-t //) `~ - ca sia. INJUBY AT WOSK: si~. tLACE OF II~IJURY: rw~ Ho-,K. Fa.~, zir. i.ocwr~oH c~rs covxr~r arwTs ~ f~~/Y Ya or No) F~cto~7-.St.rcetor0//~ee B~ildtns. Bte.) 22.1 eertii~r tlaat (11(~ ateended tb «ased~ .1l.~Q.. to PIQ!ve^.-ber Z9 ,1'~Q. , tLat q)~) Ls1 s~v t6e deeea~ed alios m ~. 18 .aed th~t deat6 oeenaed trwn tbe ewses and m the dats wd hour ststed abwr. 22a. S1GNA21JRS 1~1~`~~ ~~afkt-~ •i?:wu uf these 22~.iHYS[CtwV'S NJWE l1YVel MILTON GUSACK, M.D. ~ ~ p_~ishable ~!:e or imprison- 23a. BOHIAL 23b. DATE 3aNAlfEOFCEMCTERY «c ~~~ t~oth. a~o"w~°.N 11-20-80 Ad~B Israei Ce~ 2a. FUNetAL HOl1L ~...~~.1..~~~'~~g l~f,...,.~~ w~ a~aap~•c ADDRESS 11 ~O S[l1'311 P W i[P ~ M1R1~ 11 P! BLIIARICS: ~ AY~101'~~ jf Qtfl~ tOi Cf'tRla~Oil ~ ' i'4 ~~,pROED IM 0~~~~ ~CCO~Ot ~00~ ~Ktt. FUW~~ """--"' ~ ~' ~ ~ ~ICi~ E7[il ~a.oau rcr~r~co RIC • ' ' CLERK C1R!.il~! LJUfii ~ ' _~ _ ' _ _, _ ~~~ fi ~` _ I CERTIP7 thst~ths , _cart~ficate flled ~ , ~ ' Colutb~a De~pa,rtaen • ~ j. ~w~~: t~: yf ~., 'r!7ta',~i i ~ {:..~j.tj,aG.,y;.~-~ .~_ - ,. I~W~'1BER 28~_ 1980 - Dat~'Yssn~dj'~•. tT~ r 1== ,~ : t • - -- .+: ~ rr y`` , - 226. DATE SIGNED ? YS.N~ ~ DiRE~CTORO ~YS! D 17 -7 9-1 98Q 22d. ADDRES3 2201 L Street N.W.# D.C. ,CREftATOA . LOCA770 lCttY. fo~cn, orewinbl (8faft) ~1 # D.C. JZSa. II A~ A~Sb. IIIiDERTAICER'3 Et,p~ ~:4~- `~' ~ ; . w . J• ~, ..... f .!ti . ~. )/~! •s~= ~ F"'«I~~. - ~~ ~ .' • s~ ~ 6'~",~ : . ~, ~-~-, ~ • r ~ : - -- - - ~-'~ ' +r above ~is a tzue and earzK ft ~ n order xith the Yita1 R ~ of PuLlfc Healtb. s .: " " ' , -.~ - .: ' - . ~~::~ ti I ~ ~~.. .;.,`~--• _ ~~.. ~.~ • ~ ~ _.;~'.•'4J~ •.- :- •'-r • . ~ ~ s~ ~~),~.~'~Y' '~i':a,~f~'i~<,! 'a•' '~ ~,:~~:.~ .~ ` Vw c.~x • ~,` - - ---- -+- '~ • • ~ -. , ,. , . . - ; - -- ,~:-.:.:t - . - . ~~~-:~ ''~ llOT YALID i1I~011T AAISSD SFJIL ~ _ ~ ~ ~ . ~ - : ~ . ~ ~ • ~ t~^~",~ ~ . ~, . ,J:~,. ~, • • i~ ~ ~ _ ~ / //~• r ~~ ,~ .' i' s~~us . _, ~: # ~. '" . :/~ r =: -3~ O~UI ~• ~ " Ql~ @Y, : _. ; ~ Vitai Re~osda. Divisio~ .' R: -- -- ° ~ . • ~;;~; .. + ' ~ • `•• t _` • +r 6j f '''- ••sf ~Y~~r--- - : f ' _.~ • ~ ' a • • ~ ~• ~ 1981 !~`~ 23 :~' .1= 2~: 51~'~'36 ~,[!~~,c~-c::~ 5~ lli~: L~:~~* •~i.,~•- F? f~ C:: ~r' PC t; F t. "- f1iD/~~~~"" ~ . . " ~ ~ ~~',K347 PAGEI~O , ~~ ~ ~. ~..~ - _ ~ ~~.~~ . ~- _ ~ _ ~~~ u , ~