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HomeMy WebLinkAbout0960 ~ ~~3UJ~ ~ ~ . . . : s ~ MISSiSSIPPI STATE BOARD OF HE/1LTH - OFFICE OF PUBLIG HEA~.TH STATISTIC-3---- VITAL RECORDS ~ . , R~„ISTRAp'S c~q CERTIFICA? ~ OF DEATH STATEFlLE ~ ':u1J6ER 6TATEOFMf&SISSIPPI NUMBER 1Z.~" . ' OECE~iEO-NARiE f,rst M~dJ4 Usl . E7( 3 AlE M(41onU~. y.V~ar) a MGE t S~xafy NTRS. dVCk, , S.~i AGE AT U151 ~ONIY IF UNDEH 1~ H ONLY IF UNDER 1 pAY 5 OAT~ gtq1N 1~~. O~Y. ~'~?a~l ~~a%NTY 1~~TH I 9 7 9 . A~+Ni~an hdfel.Ht.) a~qTMOA~ 1 SD. IIOS j SC DAYS ~ SO M01~iS~ S~ WNS White 62 Ywn~ ~ ~ ~ May 29,1917 1 Warren ----1- -1 • - :O.pTVOriTpWNQFpEATH 7c MOSP{ULLO~OTkfRIN$TITUTK~1! V•aac~Mrv~t,•~e~tM.yynr~e~i«t~AQr~6s. IC tfWMO6DOAlf!$T,SPECJFV ? ~ °y '°"'•"""'~"~°'°'""'~'°°"~Nalls Ferry Road INPT,OUTPT.EM.CR AM.pRC~A ' . ~~~~~r - ~ - - ar~'pncllt~/ - 'an ' ta ~I~ Fi 1 ~ ~ . 5 9$'wlt 7 9 GTQENOtWNATGOIJNTR 1~S_MAr ~~6HRr~b~1~?i1lb. il-$l~v~V~~~Q~~SEIn«~~.9~'~'~++x'+n~Tel~ VWISGECEAi~7£vE~:K . VM1 FO.D'yOR OISptCA~t) US~.R4AEU~Oa'ES~ Miss~~sip i USA l~arr~e~ Annie Cousins ~~~•~~Y~? N~ tl OR.G~IOROESCEVfI5~e cAy:acnna~. r 1~.SOCMISECUR~tYNU48fR ItSa USWIUCCIN'AT~ONIK.ndotwaxdon~ tSt ttlNJpfBUS~NES$ORIt~t?USTRY ~ ~~Wn.~hoarnsr~c:~ 1Ar••can.NC~ ! -1 --~+wstolwmknqMe) _ - ~ A~?er' a~ ~ - 427-07-59~o_ !-Deckha .D{~ ~ire - ./4~Q p$ En(]1j'~ eer }5s StilE~ TATE lo'D CCYINTY 16C CJ YCiiT()V4t: ~tNJ+UE~ YLiM!15~15f STREE`A~Y~~Ii"QE~~AU~uL!{~'~t:H ~ Mississippi Warren Vicksburg N~~~"~a~~ Route 10 Box 326 ~ ~ i7 FATHEH-rLI?tE f~rsl MLOOa lu~ tE Mp7HEq-NAAtE Fr.st M,ouM Ma.itn ~ Louis Rist Sr. Fannie Edwards ~ 1 T !9a W F ~ I,tANT - NAME ~ N pnnU lA~ I~MtU. w RE ( nel aiM ~~wMrn a ro~lt tnO OOa nunMer. Ot Iow~. Stat~. ZI~ ~.)dr) ~ ~ Mrs. Annie C. Rist Route 10 Box 326 Vicksburg,MS. 39180 i 2~a UFW~C EMA7 ~Op CEAtEtEl~C EMA -t~?ME l tiON1~Y~~~) 2U EMSAIME 'GNA' E~•:..NU~aBEA : aEUOVwLiSO~cM1 ~ ^ / i B~~~~c~ Cedar Hill - ~ V~c.~~';~.~S~S_...,~,~ "'~~h r~~Qif-7'~1? i 2 t ~ 2;~ E. a E-N: ME 7~c M~~U G t nu ~nObosnumber_G o•'o.rn.5ta:e.ZlPcw: Fisher Funeral Home 1830 Cherry Street VicksbLr~,MS.39180 .2a C{.h ~~EN-NAMEIrypecrpnM) i7b Mwlti , E55($trMSndnumEerproutearWOOtnumnerGC~~•~_w^ Scate,LPco6e: Ao~othy_H. Breland 1820 Clay Street, Vicks~urg~ 2~~i~sissippi 39160 ~~3a :04'+lDOSldmpu.pwt~yt.Caat~CCtwr~dallMten.e.6atl.in~ jZ/a.O~+MeWsesclexam.natqna.+bc~~nvestgaG^.r.:nn~op.rt.or.ysa:r.ccw>N T~n 1 p~i~t~r..;QyttO:Ili~:a~sGSlatld T1M 1 itihehrtr.Q~te andP 3ndOt1llat?•eclu:CSrr a1N SprlAtl ~ u~l~ ~ ~ to oa com-} 51GNA7UriE ~ _ - - - - - M~ ro De ~,n ~ 31G12ATURE. i1TlE ~ ~Q/fJ ' C'~~~'~p ~2:tG DATES:GNED;M.aY.h.D,t~~_~Ieti~ i"tJc MOUROFDEATN pk~edby ~2ap DA~ES:li1~E0~ .Dar,li ~ j<<~ kOV O~~~c~~ ~ pnr~oan ~ ~ T p~ ~ M1Ol • ~ 1 OO~OM~ 1 ~j j aj~ C/~, ~~G ~„L J caon~r i r^ i 10/~ 1~79 ~ 4~~5 T orrnaC,ca~l ~0 NAMCOFAT!ENOII:GV?;r.^_ICW~IFOTMERT?4ANGEqT~~EN ~ eu~ncr ~21~ PRONOIX~CEOOEAD(?~onm,pay vea~) ~ 2~e PaOhOU:~CEODE~O , e.im.e~er ~ RrpeorD^^~i ONtY ~ ~ ~rl._:,•~ ~ ~ ' ; ~ ~,a/Y2/79 ~ ~T~S:oo ~ , w,~MT}i iSP;.~iii, ~IWkEe~tATEGU~EiEnterorKwuseor.r~) ' - [1`ci.TH ~ h~~en,~ratw~~r+orsc; i ~ .QOealh i , ~ a usfo~ t,~ g~art &ttBCk ; ~ttm~di2tely ~ ; ~ Dl;ElO. ASwGOtrSEGUEhCEOF{C~,k'(X1lU~.HOrt~) ~ !~••rtie~Dlt..eeno~set . 1 r .,i ~ _ ~161 i . j ~ Dl'f iO.OH AS A GOfiSt:rl1ENCE 0{" (f mtr cxie u~ese onffl ;.r.ter.~~ t+c' we~~ v,u; 1 i 1 ~ ~rd~Hal~ ~ 1 ' ~ {CI 1 ?7 ~ARTt OTHEHS!;aM1'FtGKfCONLITIpKj-Cqnd.t~pn3Cpn•~~pui~~+~toCea~~D~~not~Natedtouosaq>ver~~nPAqil{~) 27 AU1~Y 29 %YASG~SERfFE~i1~tC~0!~F01CA. ' I ~ ~ ~ IWrsp~HO C7(:.i.ti'1~R(.RC "C~R jyTO tteso•saol @ t 29a A;;CtL~ENT. SIi:C~CE FK.NI~Gr.`E PENING I 29t+ GATE Oi ~'~~.;RY j 79c N(X1FiOF S!l:i1RV j?9J QE~CkiBL HOW O~i BY K1UT MfANS 1~ CCCU~HE `J V;ed 1 INVEST1GAiION pR{}k[~T~pMtNEJ ~ {Mo:N.Oai.Yea~~ 1 ~ ~ ~a~n ~ ~SP!ar>~ ~ ~ ~ ~ ~ ~T ~ 1 1 m 1 ~ 1'~::o ~29e W~l;~3YATWGfiK j2!~ PtAGEOf!ILft1RYt4ec~y?IC'*e fa~m,Vr~st. ~i Tly IQCAi1CW :-,celoircnYen~nLer C~'YCrtC.vn jtate i 1+es w No) ~ Factory etLCe wru~.nq. etc i ~ ~ c-t~..tls ~ ! 1 ' 1 1 1 € ,~i 3~., HE ~5rqrw • ~ ~t C uif/~~EPELE~vtJ~Muntn.Dry.v~~.~ ..,r_ :r;~'.UaE~ - - " / ~ ~ ~ , _ - g ~ € ~ THIS IS TO CERTIFY THAT THE ABOVE IS A TRUE AND CORRECT COPY Of THE CERTIFICATE ON fiLE IN THIS OFFICE. ~ ~ £ Bo, , ~ + ~ j~ s h` ' . i ~QO /d • ~ ~~~G~~ ~~y`'~o~ S~?~. _ .s,` \,o ~~ro~ B CobD. M O ' October 25th, 1979. Dav~d Lor.. s:r `~Lr'~ ~ ~ ~ ` ~ `'a STATE MEALTH OffICEq STATE REGISTAAA ~ .h~ i ~ ~S = /A ::r_~~:~'3~'~i~.-.w=~=c'~ t.~~Ef:;~.. ~ ~'sfe.~~ve-..._ - = =-+..~.-^.:r'.ry:.:~- ~ y t3;. ~ ~J - ~ n € ' .i_ _ ~ ^ ~ 1~' ' ~ si~~ ~y ~~j(~ ~~.i.iid, , t * _ [ StLIV11('1LlQLP Li4iID St~Z[3 {.<4~T~ LSAMLTiO~ . S {~vc ~i I ~ J- 4 ~ , ; . - . . ~ . ~I~l JJ~iJ...l`~ _^~,i ~3~V r'-~'' (J~U R ~ ~ .in~si.~_ -r.-J.: ~i, 1... _ z . _ e. . . _._...CS .~-o't"s