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HomeMy WebLinkAbout0928 / ~ ~ 1~~ • _ . - C11'k: DISTRICT OF COLUr1B1A DEPARTMENT OF HU1~4AN RESOUItCES . t.cad . ~ ::;;_,~~,,t,~ CERTIFICATE OF DEATti 8~- 0 0 5 I 7 3 311~~~' . • . F~?e Ko. F1LE llA'fE - Yeo? 1.NAASE OF' Uk:CEASFD ft~st bi~drlte latt 2a. DATE Afonfh Lay ~2b. Kour ot Uea4~ , l7ype or Pnnt) OF • ~ u ~ ~ C R`~ ISS ~,L.C l ~;:i i: f newrii 'L'GUSi ? ~`81 ~ 2~~1-~'I~1 `i C.. ~ 1~ ~ U, _ a ~ ^ _ - t:t uf 1D- 3. S!a 4. COLOR ORMRACE S. Nevt~ 1ltarti~d, Ai~mcd, ~ 6. DA1'E OF BI}tTH 7• AC,£ (~n ~'rars ncee l'. lt L_nCer L'4 Hr~_ . „~i,i ~ M'idowed, Drvo~ced: S~.ecd) tast 8irthda~ ~ Alvntns Ilaya N.u~rs 41tr,. ~1~L~; CAUC:iS1:~: "'.ARRI~D APRIL 1 ld~ 1 „upplird_ g, pLACE OF D£ATN IN H'~thin tOn, U.C. 9. USi;AL RF.SlUEhCE iu'nr.r QeCfatC4' 1«C/I- I(IM~Ytl~f:ilh, miidrr.cc 6 Ae/ore odmik~on! NAIKF OF HOSPITAL, Nl,'RSIKG HOASE OR OTHER INS'TlTUTIUI a. STATE ._C'~r.~ Cc~~.O~1±~COliNTY j:O~R~ no! in ~nstitutiun, t~~e strrct oddrvasl I1~SIDE. CITY LIM:T~ c. CITY (SPtiC~' YES OR N01 ~ ~~r.-,. i.. FOX I'IRE VI:.:~GE(272~ ~ ~~s ~',-._,_Z,FZ ;~~,C,~ x:_ ~ DZCAL C.~ d. STREET ADDR£SS /ll ?urui, ~~ue 7ucation) ~ rittcn . ...1 ,n per ~^:=^~?,T;: j~~ bit~cl. IOa. USL'AL OCCUPATIOA ~t,~c.~ ~cind ~ crk lOb. ICI!~ll OF HiTSItvESS OR 27. RIRTHPLACE 12. CITIZENOF WHAT CUUtiTRY° done Cu?in~ mnst of u•urklr.~ :i;t, cis n r! -ft~cd ~ INDliSTKY ~(Statc ur /o?e~rn co~„try~ ~,r._~~v C.FFTC~. L1S ~~•.ty ~ CO;:'_;L'C'TICL"'~' U~A 13a. FATHER'S I~AME 13b. MOTHER'S MAIDE!~ \A~1E 1.1. 2~/lM'E OF SUP_~'IVI`:G SP~)i'SE p,= ^.T u~^ ~T,~~' S1EFi~~::I~ D'J PLUS: ~S I ::.AF:JCRIE E~:^CiiL~;Y _ ~ rrt~_.ca:e be- 15. E~'e~ in L'.S. 1ti.SOCtALS£CL'RITY KO. 17a. INFOItNA1T }'SL:1TIll\'SHiP TO 1)ECF_'ASEU 77b. ADDRESS 5trect CitY Statt Arm~d Forces? ~ 2~'y8 1%C%'--'~!~T:.~ , r,rr:nanent n , ~ , ~T A^ TZf.~`/ ~t rT '',y T-' TT' - 1 r ~ ~ 1 Y=S O40-0 -0~., :•`%-~?~uRZ~ ~C. r. ~-c u: e1 ~t'fIPR , 2g. C 1USE OF DE ~TH: ~E ^tcr u.^.I~• ore: cause Per tin.~ :u. (ai, (b). rnd (c). / ~ Inten•al F•t~rcen PART i. DEATH N'AS CAUSED 8Y' 1 Uuset and Death: c~ecuted. IMMEUTATE CAliSE (a) _~,t l'.D! Crl.jT+._O'.:~~`~ tiRR:.ST ~ 1 a:T1~tJ~F i Condi:i~?nt, ~,•'cr.y. whun Rsi•r .asc t„ DUETO lb) .C~.ti~~ ..._L .C.~.':1: ~ 1 1'~~t s~.:}~mit a 7_ c6nc.- caur.• ral. stat- - ^ . " 0 fn~ th.e underhin~ ceusr ~ u: Death ~t. _ i. i~'i r~i 'ai!. Tl.' 'Tt I~ ~ 1 ~'ri'-= - •::r!ment r DL"ETO (c) ~i.~.___..1~.~ ..~t7_._.~11___`~_~ - - - 1;e_ ~ V PAR7' ll. UT[IER S1Gti1F iC:.\T CO\ll17!O\S- c~~ntr9b~itir.6 to d~ath A~t not 19a. Al'TOFS2"' 19b.~tl"• t.L:'err F~ndinesC~.nsider~~ related to tt~e terminal d,srase condit:on gnr~i in part 1 Is) ~F.S ON`ti~ in ll. lcrm~~iu~ the Ceus! of De:ih? ,.~::~in 4g 's. ~r, ~rT•^ r,^~- *'j T~ :::.=~r~:~C:; .?T~:: FT::~--iT, ~};"c_-~ • L~',^.'.:~v ~ F_ Y~,..~~ C::_~=v.:_~_ .~~eath ~ IF OFFItAT10\ \1'AS YF:RFUFi~,i.~YOa. D.4TE OF UYE:1l.AT1UN '~Qb. CONDIiIOti F~R K'HICH YFRnTIpti , - GOMPLETE ITEMS 20a and 20b i ! 1~'AS Pt:RFOR1fED I ..~~;a:inn of V - - i---- - t~: thY n15- • ~ 21A. HUL'R AtiI? 1:ATE OF 11JCR1': ~fonth.D~l'.y~ai =~c. DESCRIBE HO~~' IIC]liRY (1CCl'RT.ED la.Speeify it accident,suici..e. hom~- ~ r.otu•e o/ /n~~ry' ~n Ycr~ I or Part II/ . ( c~:urnbia. V cide, oc manne[ undeterr.iined ~ 21d. 1\JL'RY AT K'ORFi: 21c. PLACF. OF ItiJCRY: li~~r-~v. :•~•n:. 2It. LOCATIO~ CI'fY COlitiTY STATE w (SPvf~/~ Fet Gr .\'i.~ fae:or).-~.refturU!f.tr Hu:'.I..rA. Ftc.~ , ` i:.H ~ . i ( Tt':..~-----------• 19.S1.~.._. to -7 :i~i_ sc-•:----- • ly t=l-- • thet !W ~K'f! I~~t r'-~ 22.1 ccrtif3' ~at ~ Ithic hospit~ll aL'[PCa:ti, Lhe deccased fw• 5.7.-.~.~.lJ ----1----~ ; ~ cj~~ ww the decea~cd ali~~e on __I__.::.i l:.i;______________ 19 __G~..u:d tfiat drath occuned trom t}ie causes and on the date aad hnur atat~d at,o~'e. I: `;'i I;L~~_ ~ya. GtiA URE ~ 22b. DATE SiGKFD ~ r A:TE!~DI\G 7NEDICAL STAFF . . .T„~ C C '7i~~ ~~~VHYS. DIRECTOR:' YHYS. U i:~~l~u•:_ 1 UZ t 22d. ADDItESS - ' thete 22~' pHY51C[A\'S _ ~~~v~c f ~,f NA~1E (TYPr) ~.-n:rr ;.~i, ~~~~'_t _•`.J C~ •'~C / / - e .ri~e118h1o ' rr' ! C:I . i'~~)~: ° -:r,:;~:isOn• 23~. AL'RIAL ~3b. LATE J il3~.tiAl1EQFCFASt:?EHYOKCRENATORI 23d. LOCATW•~ iLlh, foun, orcounfvl (`ilate~ tl ~ ee~iov4~, x' 8~8/31 ~ Lee's Crematory Idashingto .C. g _ ¢ 2~. FUI~'ERAL HOME : 1., 7:;: ~T Fj~:;:~:FW_T rG; ~a• AI:ER' SIGI~A E b. L"~nE~' Ali°P._S G O.\^~ e ADDRESSII.POO *~~i': r~_~Sr?~T' ti~'!' ~II.Vr~p .~i~ :~i f REMARKS: ~ ~r '~~'.YL~iID " • . ~ ' ' d So~' u~r~~1bY' ~j~ ^ ~ ^ ` i r'ir~ _t 1 V Y ~-~~J~i,~-~ l_ ~7/'_~_ '_~-,:;J" - ~ C~~~~~~. - - - - ~SedicallE~ca(r?i~ r ai(Rr fesentati~~~' ~y~ y • ,~A~ . • Date _ i-r-r-r- ~ ~ ~ : F~..~ ' . ~ f~ ' v . ~ f " . , • . ~ C~?'i F~ t:~a~ ~.he ~boti•c ~s a ~ra~ a-~~ ~oTM~ec~ 'r~paeoductip~of t~:~~ - o~i~inzl cert;fi ~aLe :i? e:i ir, o*_~er xi~fi ~t";e `~TkI, ~r~~OR~S JISIGI: ~ ' ` _~T~.,-..._r.., r ~ . ^~F.t~.i!~:?`'T oi Pv:;!~I CJl:~}I:T:~; ' ~ ~ ~.:,~....~~_.c~;.,~r:~ L ~ t. _ , . „ , , t° ~ ~ : . . , 1J.~J.~~..~• J~~.~~~.~i".~l 1C~ ~G..~ ' . _ . , ~'r_~" " ` ~ " .T" John H . Crandail , Chi e= . ~ ~OT YALID WITr10iJT RASSID S Vita1 Recor3s Divi~ior. ti ~ ~ 6~~ , ~ ~983 . - ~ r;! 4 5 ' ~ . ~ ~ ~ , , . . ; - . i~A ` ~ ' 1 = arlaK v?cE ~ . _ _ _