Loading...
HomeMy WebLinkAbout0132 - ~ . • _ . ~ . ~ . . ' ~ ' . . • . . . , . , . . . . . . • . ' , ' _ ¢ , . . , . , . . . ~ ~ ' . ~ _ ~ ' . . ~ . . . - ' ~ ~ , • ~ ~ ` . . ' ~ . . . _ . ~ ' . ; . . . ~ . . - . ~ ~ . ~ , ~ 1 • . . ~ . , ' . . . . . 't . , , . , ' r + , . • . . • . / . . ~ ` - , . . ~ . - . - ' : i . yti . • , . , ' ~ ' f ' . • ' . . , ' ~ ' , . L~- ~ . ' . ~ ~ ~ ' ~ • • - . . ~ . . ~ . , , • ' ~ . ' ~ . . . , ~ e_ ~ , . ~ . , . . ` . _ . . ` , , ' • . ~ . ~ ' ` . ~ ~ . ~ . . . . ~ ~ • . . ' .t ~ ' . - , , . • - . . . , - . , ' ` • ' ' ~ • " ~ ~ • - • . . t: - . . . . i , . : . ' • ~ . • ' . ' ; . • ~ , . . ~ . ` . ~ ~ ~ • •4Y,f°....r..-,,+~~~,.«~.,-._•-•+r+.•r'M~.~x-..p~.ar,Yr+~y...«..: ,F.:-r.~.-.vr;.~ rt!.~'!"„7RT!!°4'[RL~'fT'r+.~~4:•+sv-.~~Ff~r'Fce!r.a~ 2ara~-;tn°,.~-_- !4*~:• ~ i . . . . . . . , x ' ./1J if~r ~ ~ ~ ; _ ~ : . _ : : ~ $ 3 4~~s~.~:6~s.::~,y,~ ~ ~ ~ ~ OHtO DEfBARTMEMT ~F HBAI..TH ' • ~ p~. ~ D!VlSIAN 01r VfTAL STATISTICS • St~1e ~ik No ~ ~ t~ p;K, 480 ~ CERTtFlCATE OF DEATH ~•r • N+ ~ . ~ GD{M~i~Y • CE ~aa brfotc , • ~p~~ iactiartan: ~a• c GD{M ~ C/~~~,~~ - , (,.ii~i,B ~ . STAfE J'.~Ii,L[iR CWNT1i ~ L~~~„~„ ~ b. CIT11. YlLlA4E. O~ IOCATIOM c. LENOTi1 W STA~ 11~ 1? c. G~Y. YIl1A0E. OR tOG~lOti - _ . . T , ___~_~kn~c~~e F~ ~.tae~.~e HAME qt II~ Rfl M~J~~I M qifdlHlM. tis~ inrrc dl?~uI J. titEET AC~OtEIS • ' MOSIITIIt O! ~1j ~ /~~~_L ~J ~ ; ' INSTIiV110N ~~~GfJGP~/N O~~ GLi. ~i. ,t~~1 ~jI LXl/[R.e.~ALtAJL 1[~f~ ~ ` 4; IS,KACE O/ ~lAM INS14f ATY IIJAl1iT li R[f10fNCE INi1D ti~t' Ltatlls) IS tESIDENC[ O!i A/A~IYIt x:; X . . I ; ~ ' ~ ~ RES ~ !1O ~ l1Ef MO 1 rES O tl0 ~1 - - ' AECE/1S D ittt i ic rt ' e. D~ E ontb ~ esr ; - - _ (TY?E Ot ?lIM~? ~ /~V ' OEATH ~i~l I~~ ~~2 _ ~ f. SE1I ~ OR O! RACE 7. AtAtt1E0 • M[Yf! AtAttlEO DATE Of ~I1M 11GE (b )tai I Mi~r 1 YNt 11 tl~1i~ 1i M+f. a / t iirlElilJ . Ma~tb~ Dqi H~ru Mi~. - ' ( W w~oowco Q oim~c O / ~ I ~ ~ l0ir. UfUAI AGYalIA1tOH lGirr i~l ~J r~ri /~u IOi. 1(IMD W WS11~[tt Ol I1eWtTtlf ii. {ItiMItACE-~IVr or /e~~it• 12. pTIZEN W ~iv~ ~i ~viia~ tib. srN if rNir~) ~~r~li)) W Itlf? • Fir~e Lanc~e f~.la.inv.i.~ew T a~a,a I ~l,`~: ~ . • ~ 1~. FATNEI'S NAME U. A10TM[R'S IPEN NAME ' . /'L ~ ~rft~~u+Wi , 13. WAS OECEASED EYE! IN Y. S. AMIED IOtC~3f 1~, SOC1Al SEQJtITP HO. i ` ORM ! 1VATURE (Y~i, vr r~/~w~l ~,~jr~ ~r 1Ntr ~J irrtir~l ~ 't O , ' . ~ • W f . . It. CA S~ I ~ e~~ r rt j~~ i~t fx t). (t~. ~ IHTERVAt ~ETWEEN . . ' tA~T 1. OfATM 1YAi GUilO ~Y~------~C`~ ONSET ANO D ~ ' ~ IMMEDIATE CAYSE 1~1- - . ~ ~ ~ c..~r;rN.,..~..• oue ro ~?i _T " ~ • _ . rlit? ~w~ nr~ - ~isre t~sr~ (~J. . . - ,ia:.~ ,.s..- uuE ra ~d . . . t~:,j t.~r. T ~ n. owu srwN t+~ns~~ t~nn rn~ r~ ~an ~rr ~~t ~wru» n ~r~~~a M~au~ c~awr~ ~~N w?~n ~(sl 11. WQf AYTOIiY • ~ rE~WilAEOi . ; ' ~ , , _ _ ~ YES NO . _ li~. ACCID~NT SUit10E IIOMlCIOE . 0 ~E MOW~ tY OCCYRtED. fif- rr~ o i~j~r~ i+~ I~?~ I a Pw~ !1 a/ Nrw fi./ ~ ~ ~ ~ ~ _ , • ~r TIME O~ H~o 1M~~? , Dej. j'rw 3 _ ~ ~ . - ?e~lvirv s.. r6 _ - n . ; f 1~- ' ~ . IN11?R'? OCNR~EO Q I /LACE Of tltJV (t. j.. i~ er ~i~~1 ar~, 70f. pT1, Yllt , lO~J1TiOM COilMTY. fTA . YEINltE AT MO~ 1M11l1E /ww. lor~. itr l. a~~ if/s.. ~fr.) , ~ W01AC A~ WO~K ~ ' , fl. I ~Itr~1~/ rM lrriy~/ fn . lN1 ~w ~r~ ~lirt s~ ~ , Ar~?i ~rtir?tl ~t _~~"r w~R IIr /Wr u 1 i~i wY te~r{dp. jnw /M t~rx~ Nrttl. - ~ i NA?URE ~ ( ~ ,~~s; . ~,?n ~ , 6 - fi.. Wt1A1' C • ( A. TE ~7c. HAJ~AE Of CEJ~IETERr Ot CLfMATORY 2J~. t~DCAfl • (Cit~. a. x towfr) ) • ii . ($~v.~ A ~ r 2~ .W~ ~r " - MAME O? EMiAiMER . It1C. ru i ~a i iu i~~c. ~o.~ . . ~.1~aYltal ~a~e~_ ` ~ ~ u. wNS~~~ n ~u+o ~oo~rtu 1si ao.~ tam ~ ir~?~f . ~ n~~~ • ~ . . ;ir. o+~Tt e~rn rr " ai • ~ n. su~ ~sruurs -;~~~s~~ g~~~ ~ 03 ~~~E ~.32 0 0~ . - _ . . . _ . . . . - ~ . . - . . . . ~ . . ~