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HomeMy WebLinkAbout1464,1 1 i ,~ ~ ~. , ~3 , S ,I ~.. I V~ ~ 1 . ~ `L ~~~ J1~~~~ J ~~T ~ , . C~RTIFI~~-TF 4F GEATM ~y~,~~ ~~~, ~,`~~f ffC w'. ~0 SiA1( pi CAl~f0~N~16A-.(1Ef~A~'1'MlMT 0~ ~`UBLvC MfA~TN . ~Zv~ Afi.!2'tk,iYr. ~ D _ . _. , . . . _........ ____ .. _. ......_._~.._~.___.~,..._...... ._.._ _._r. _. ._._.._.._....~._ ~~, ti~~:k ~~i bf ~ E~~~E i ~~,~~ ~.r~ !~ n~ts1 r.ri ~ k us+~~s( 1. D~TE OF OCATN~_~orr~ Nr rr~u ~2~ w~tM _ . .. "r ~F._~Ni'~I$ , _ ., ... _ _ . ~_. i~i~t~~.:~„ . ...__ '.....~~'~,~~ _ _~~ i r I:1 Sf.M ~ 1 i',?..'~7 UA AA.[ 5~IN?r+Ylpif ~4.+~~~ Me M 6 O~TI 04 IniPTH ) A''v4 ,u, ~.~.e,. ~~ ~,wot~ t e~u u uMD~~ 7~ Moun F'~. Ga-u~~~e~~ _~_ ~!~~ ___._.., ~"~ .~,_..?~~~._ .__TO ~,.~ DECEEIENT g NAME ANO BIkiNV~ACE OF' t~~"NGN 9 M~t~11h tU~ME ~NO YNY7N%.ACE ~ MOiNEA f'ERSt?NAL ' A 3~iae1 R~;~ch~.~r«~-•,1tt~Lz'~+- C1,~r+~ 'lk~'~c»---~1s~t~"3a . _ ..._ ...-- - - -.. _ ~__ __. _ _ _.. _._. . ____._.____._. _._._...._._._..__._..__~ oa I~0 i11~~~N Of WHAT ~1~11NiR'r fl 50CIAL 5! U~I~Y M9110NF.q li ~.+uu, w+c~watU ~~DOWCD 13 NAME 01 $URVIVING $POUSE ~u wi~i LMTIIIYl~ID[MMliy(i I . 1.... WN»:f. SNt11f c~.acE ~i~ Df.ATH UtiIIA~ RESI{)ENCE ~ ~~ m.TM xw~r[e u ~ ~' ~ ~rrnn~n~ rvr~~ n~o~~~i ~n ~~~ ~ - ~ ,~.~,;,~~ ~~ ~ ' { HY;ICIAN 5 OR CORONE R ti ~ ~ CEKi~F~CA'IiJ"i ('i ^1 F~.!nENa~ ~!REC1~1R AND LOCAi RFGISiRAq ~~ C.7 ~ ~ y c rn ~ ~, h~ Qi ~:ao,t d ai ~~F I =1 DfA!h q uJ J!, ~I =~ ~ !!v.IURY WI SIINFGRMATION Dnitbd States ~84M2~li(r}' ~_iffckrwnd ._..___.._.._..__,._.. ____.___._ ..__. _.-.-------_._~_,_ .__.....______.~.____._ 1{ IASI Oll'U~'Ail(~N 1~~ ~x ~„~M ' If, XAM! 0! l4ST {Y%OritY4 ~OYIAN~ 04 17RM !1 KIND Of INW5IF~Y OA BUSINE55 ~. w~.i ~r,oNr w rri ~ Housexi.f~ Am Haae Hamemak~er 1A~ PIACt OF DLA1N H~rL C~ N~5-nu d OTMP.p ~h r~i~FKT r~tarTr ~Ide SrftkfT AD{HtE55 •-~+n~n uw+u~K~ a ia~na~~ ~8~ ~~s:o~ c~fr co~~~;~ i~n I ~~nc~~, n: a so~ _E?~4~s P.ea~.~~Y.~.~.~_.~1S~L... ~.~~~.S~~s A~nu~ „_ ~ Ta _ IA: 1~f10R~OWN ~l6f (~~JNTY ~Id~ ua+epnni~ta~~l+q~~~BGuk~.a~~~~N(NIlO~Y I,oe Aneele~ ~ Lcm,.~r~el~t i 6~ieeke ,t~~16 We~ka ~f.~ 19~ 115W1 Rfti;pEllfE -S1Ntf7 AUD~flS f~~t~r ~~o w~a~ a~a+nu. 19~ wy~p1 C~~r CoRrCM~r[ ~iriTS 20 N~ME ANU MAIIING ADDRESS Of INFORMANT ~~. t'L~. J~ rli M M) 210? --- Ooer~ Av~tme ~ Tea _ Z~rr ~ndrrer Pt~D--Sott 19~ UT1 OR TQNh '- -"" _. _"9. COUNTY -_._..._.. '19~ STATE~~ ~~~ v~J~a i~i~~ 5anta ~lonia~ ~ ~ Loe A le~ ~ C~ltfar'i~ ~, Ydniou~C~litot'ma 94~9'1 ~ ~ ..~R~.1Nfi1 ~ ~~ ~ ~:IY FNY11(IAN ~ w~~~ ~ ~ ..u~. ~ ~~ P 1~i4M C~k (ilkOh( ~~~~~~~~~rN4q ~~ ~.~ ~ Ij~C ~ATf S~~h~ ~, , i .. .. ~ , .. ., ~~~ I I.M11~~ICY'h~~t ~ ' ,A, l I I ' 1 ~ f ~ W 1. IF: yy~ ~ ~ ~. .~.~,~ ~ ~ i~ •,.~,.,~i. Ir~.~ I . ... " ... _.. ..._ _....._ ~_~...~ _.~-._.-~.. ~ n~ ai.. ..~._,., ~" I I 1 ~~ ~. ~ ~ . , , ~. . ~... ,,.. rA~~l~'t:l~i7n 71r A, DNf~Sti ~(t~ ~.~i~.i ~..~i.~,. . ~1-1~~~3 .~~ J6~7Y ~ ~- ~~ ~ Y ~~~ ~ ~~+~vs~o.~ ~( ~ ~o~ ~~'~~ ~?~ ~~+,~~~ ~ n~ ~,, ~„~~ ~~.~~~~ ~.h OATE ?3 NArE OF CEMETERr OR CRCMAIORr 21 EMBALMER ~-~S~G~~tuqE ~~~ qu~ ~^~~~.~o~ :~iENif MurlE~ ~ n~ r.xi~~i o~ I ~ , P . , ~~~1_. . _._ ~--_~_?-1T-T~ .----- S~._ . ~ _ _ - ~ ., ., ~ ~ i ~•,n•,i~n •N`~ • ~ r.~i. . .. I 5 r ~M~ . i n.~tit u~4 D~WI ~ r::W o~ r[n~ ~~r~~w ~i w~^, , b :'1 l~C Gi5 R d 28 ~, ~.~:~.~ - '~~1M~'~Mh~~'IY ~ ~t'M~ ~~^. ,.~~,,,,,.. ~~ ~ ~E~i ~ ~ '1,'G xo~nt si,~a xor~~ 24 PAk1 I p~n7N w~5 UUSED !Y tM~t~ pN4~ On! r~uSf rtR ~ia[ ~WI - e ANO c ~YYIU~~'I ~~llSl ~ ~j~~~ ~~ r A i 4,Q'y~ rr"W /1 ~ ~~N011 ..,..__._._..._ ._...._.L-._.._....__._~~.__._._ ..._._.... _~ . _..~._._ r~7f t~„f ~0 iJa ~S Ua~iGi,l~~~ [ 0~ iti~ERYAI ~,~r~,;~~,,,~~ ~~~~~ ~:~~~~v~-a~~ ___ _ y a d~r~~~~ „e~~ u,~ • ~~„ ~r~rrn ~gi u ~' , oNSt1 -- AN; AIC . A, ,~ A \~~1~~'. ._ _......_"^ " _ __.._..__,__._.__~_.. _..r DIA1M i~f Vti~ I N ~~ ~~ ~ ~~~ I ~ Di~! '9 ~1P ~~~i1M1V0' rNl f 01 ~'~Y~ ~/1Ir~ j~~~~ ~~ A\t l.l ,~ti/~ ~~ /1A iw~.~ I~ 1 r,~'~W ~ ~vV-~K\ ___...,__ .__. . _-.. _ ......~_......_ __.. .. .. ....~._.~.._._.._.._...____.~........_ ..__.~..~..~._.__._ ... _~.. .~ ' ~~ it~ FAR~~~ ~~1NlR1~GNIfIi1N1lUNDl fINS ~' •~~~ ..' r~.. .,~n~i• o~.~~.neriu~~~~rna.~~~.~ •uaV.~»r~.n•ru~r~icr;,~ 1 . ..i.~~ . ~I l~~ ~f' ~M ~ 1~171,~1/~' ~rl~, ~~ J(/ ~~~~^~I;iA +~~±~~~~1~. +i.ro~~~o,~~i~n~ ~nor:~ ~ ~.~~ ~ .~. wi~~„i~n+o ''`Z'~'~/~.1~ ~ y?TO ltio . I ~ ,.~«~ ~,. ,.: . ~] ti~~p ~;~~~ ~~ ~ ~nw~ z~ ~~.~oi o~ ~or~ ci 3! nui u, ~~ir~~ ,:~~.; ... ~ 35 ihiua~ ~, wna- 36 +~1( Or ih~uAr ~.o.~. n.~ •~~. ~ i6e WOUk ~ ~ ~ ~~~ ~„~, ~.., I .._._.,._._1_ _---_._._ ,~ ,~„~ i _...---_.... . ._----_.._....___~_ ~ _ _.. ~ ' ~~M ~ ~~~. ~.. ~ ~ .in ,~-.n~,r, ~n~,, wn ~a a~~i ~ .i~i . ~~ .~•:r~ ,n•~ J?~ PLAI f. ~.I !NJUH~ 5teit' ~MU ru~nw ow la~~vtu~ ~MO i n~ (w ta~w, ~3I1 ,.., ~,.,.~ ~SB ~~ ~~,~ ~..i~,u~~ vr ~~ ,~~ v~c ~ a ~.~~ .. ~ ' ~ .~, ~~~. ~ ~. ~~ , ,.~ ,,,',~, ~. ; ~ YiifS ~ I ~'~' DfSCRIBE N0~' INJURY OCCUAN(D ~~•,u VOaiKI o' ~~~~~~ ~•~~• nni~m n~uv~~ ~~•uw t~ ~uw~ f.Or~D u ~~~in~ ~~ n~~ t1 ~~ ..