Loading...
HomeMy WebLinkAbout0149 a _ ~ ~ 3Q'`10'~4 l ~ ; . . _ ~ ' OHIO DEPARTMENT OF tiEf'~LTH " ~ ' K`R. u"`. 23 DIVISION OF ~~1TAL STATISTICS s""F~i` ~ Primar~ ReR. Dist. Nu. ~ _ Regii!r:r's No. ~ ~ ~ CERTiFICl~TE OF DEATH - : - - DECEASED-NAME l.r+l dfiJdlr , Er~t SEX . DATE OF DEATH C.~IoNrL, D.+~, Ysrr) ~ - ESTHER U((:HS KELLEY ' Female 4ctober - 30, 1974 ~ - RACE u~n;rr, Y~a.o, ~:~r.:«H AGE- t-.~,r ur:oee i YEA! ur+~ee ~ ~AY o~ie oF SIQiM rafo,ur,,`v.,~, COUNTY OF DEATH ~ inJi~n, ttt. f5(.eril~l bi.fbJ~y (ir.,nl .~1ut. D~)~ flourt .t1ir.. ~ rrr/ g - - «hite ~ sa. - 76 ss. s~. e. A ri1 17,189,~. Fairfield ~ C11Y, VILIAGE, OR tOCA~ION OF ~EAiN iNS~CE CIiY tIM1iS HOS~ITAt OR OTHER ItiSTITUt~ON-NAME (IJ eof iN wlbtr, ~irt if~ttt Jxd uymbti/ r ' lSDrti11 iu ar ~01 _ . ; ,b. Lan~a~ter yes ,a. ~ 203 La~r~c.--Newark Rd. , NE, Lancaster ~ ;IATE OF BtRTM /11 U.S.A., namt ~:~i1ZEN OF WHAT GOUNTfiT f~tARRfED, NFVER /.~#4RIEU, SURVIVING SPOUSE !!J ui/t, ai~c rr~irt~i u~wrtl - ~-"-'-4 ro+~nti~1 ~ W{COWEO. OlYt7QCED /S tti/7) ~ L'. a_ Ohio 9. USA ~o. -~3,arriec~ Ar. A. M._K~llev SOCiAt SECURIiY NU/~6ER WAS OFCEASED EVER IN U. S. ARMED FORCES? ~ S _ (1"~~, no, or YnEKOVrJ ~,T ' yes, S?r dot~s o~ sm+ce} ~ USL4l Rt5{OENCE 17a_ 2HO"'lH~HHY~ T 12b. JlYO ~ ~ - :Y::t:i DECEASED USUAI OCCU?ATION lGirt tirrd o/ uor4 dosr du.ixr, ~or! o~ KtNp Of lVSINE55 QR INDUSI~tY ~ ' ~ - = tIYiO. If DEAiH u qr4in6 fijt. trtn i/ rttirrd/ - ~ ~ OCCU~4ED IN Hoasewife (Registered Nul..~`~-~ „b. Homemaker. - ~ . INSisTUTiON, GIVE 170. ~ ~ES~OENCE 6EfORE RES~OENCE-Si~TE ~COUNiY C~iY, ViIIAGE OQ'7UTION Ir:5~0E CtlT LUrtITS STREET AN~ NUtabER f ADM155lON. ' - - (Sptc~/7 )tf Or noj ,.o_ Ohio ,.b. Fairfie3,ct~,.~~,ancaster es j.~_203 Ix:nc.i~fe~aark Rd. ; - FAiM[4--J~:AA'f -(:?lf - ~ .~liddlt Lall MQTMER-MAfOfN NAME ~ I~irtl _ .1fidJlt L.u! `f ~ `,S. Charles Henr Ochs ,6. Franke, Marlette Elizabeth Uch~ ' Y viAtl7NG AODRESS l~1r~<! o~ I~.I.D. rro., iit~ or ~ill.rat. it~rt. tipl - Z IhFGRN+AFVif-NAME _ ~ ~ ,~a e) le ~ »o. 203 J~nc .-Newark Rd . Iv`E LancastP.r Ohi.o ~ 2 YARi e_ DEATH WQS CAUSED BY: [FNifR ONIY ONE GUiE ?FR IINF iOR (ol, Ibl, ANO (UJ AP?ROX~Ml1iE InifRVA: BE~WEEt+ O`~SET Ar:D OF~TM W : Z ~ te. - - Q - - 6 mO t~iZs ~ IMMEOIATE caus~ Garcinoma of descendinc~ col~n ! a Ot1E 10, OR AS A CQNSEQUENCE OF, ~ - - W Condiliowt. .if. aer. - ~ , a uhicb aarr rur to S Ib) - ir~medialr raurt I~), DUE TO, OR AS w CONSEOUFNGE Of~ t rtatiaa tbt urtdtr- ~ _ . - ~ - ^ - - /~in~ t~att la1! - , -,T'i~ - ` F„ ~ PART 11. OTHER S~4NIf1Uhi C07+DITtONS (.onditio,i~ tonlribwling lo dt+tF bYf noG r[/~ltd to ~~uf[ arrrn in por! 1/u1 i.UiOFSY ~ If Yf5 :+~ir !i~+di~~s~ .•.u,~~~.~.! 11'ti o~ nol ~i+ Jrltrnririina [.r~~t o/ ~t~lb I ~ _ ~ ~ - ~1Ca. j19b. a AtC10FNT, SUiC~DE, MOMICIOE,~ DATE Of INIURY - tiCUR . KOW ~NIURT OCCUQRfD (E.t~tr a~t+.+t o/ rnjnry in p~rt f or g.rrl iit~~ !n! - OR UNDETER4c~t+ED (SQrtiJyl l.~lontb, D.r~, 1'srrl . _ 0 2M. ?Ob. 7u. tiM 10d. ~ ~ It~JURY Ai WOt1C PiACE Oi INJURY .1! bv~t, /d~ni, ilrttf, /etlor), IOCATION IS/rtt! ~r K.I~.LI. no., O? ~i!lrat, ttrlt, tip/ - W ISprril7 )tt or eo1 n/~ire b/ds.. tlt. (Sp~ci111 - . . ~ a " Z0~ 18f. ~ - ' ~ ' } - _ f: CERTIf1UT10N- .1loxfb Da~ }~t.r? .HantL Dr~ Ytar AND LASi SAW Mw/MER I A~/DiD NOT t DEATn OCCURREO .1! !bt plrtt, or ! ~•~y :~i PHrSIUAN~ AUVE ON VitW TttE 60DYf ~NOUrt~2 ~ 35 r~,~ d.,r.. 1~d, ~o ' 1 AIiENDED THE TO .~tonlb D,~r 1'trr ~AP?f! DEATM. 1 ~ rnr brrt ci m~ ' L •,.:~4i~ . ! 4.i~~/~d;o. dr.e r~ ' oECE~s~a FtoM 4/2~f74_ ~~b. 10/30/74 10~30~74 !~~e. j zi.. P.µ. rh.~~~r.i.;,r.•~.e. ' ~ CERT~HCATION--CORONER: On !A: ~,i+ oJ tbt ~s~mrn.+lion - Harr o/ dt.~~b The derrdn+r uai p~enoNnrtd dr.rd OI JJ7l G9d) ?7J~IIJI !Il! IMI dl7sJfl0/~~ in mi oDiniwr, dtrtb ~ .No+t~b D+r Ye+r Horr .^_~~l ~ ` . . ; o~~Nrr:J o~ ~bs d~fr a~d dwr !4 ~br r~~irlrl itr:rd. ~ •_i?:~; ' 110. M. I ?2b. 1e~. CERT~I~ER-NAME iT~Q[ or prinfJ ~iGNAiUR~ - Utgrtt or fiflt , i OnTE S~GNt~ , - Dr , Arthu~ Van~undy 23b. Arthur B. VanGundy, M.D. ~~,~.1C/31/7 2 M~~tiNG ADDRE55-{fRilftER . SiREEt OA ft.F.O. NO. C~iT,OR VItIAGE SiATE ZI? ~ 73, 843 N. Columbus St. Iaancaster, Ohio - 43130 f . BURIAL, CgEMAilOla OA1E 1"(~74 NAIAE C~F CE?~nEiEiY Oa CREMATORT tJCATION - ((.il~, ~il/est, or rornl~! /Sl.+tt/ ; r 1 prc:irl t „a. Bu.rial z,b_ Nov. 2 z~~. F~Urest Rose Cem. ~=s. Lancaster Ohio ~ r ' NAME Of EM6AlMER IIIC. HO.) ° FUNERAI OIRiCTOt'S SIGNATURE ' II~C. NO.) i ~ Smith 68GG A i~a. Irvine G. Smith 3844 ~ ` . ~5_ Frank R. i ~ ~ fUNERAI FIRM AND AD9RESS - ~ (ST1EEi NO•) - ; : ~ (C117) (SiAiE~ . (ZIP) - N~ Frank E. Smith Ft~neral Home,405 N. Columbus St.,Lancaster, OY~a~o431.30 : . DATE ifC'D tY ~ REGISiRAR'S SIGNAtURE ' DkiE PERMIi ISSUED ~ StGNATUtE Of PERSON ISSUIKG tEt!.~li . OIST. NO. lOU FG 78. ib/31/ rsiia=ea J. I~.ill.er ,9, 1G/31/74 „ Linda L. Str~hm ~23 . _ _ _~o~x239 ~~~f ~49 - = . _ ~ _