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HomeMy WebLinkAbout1075 . .r-- - - - - COMMONWEALTH QF VIRGINiA - CERTtf{CATE OF DEATH f DEPARTMENT OF NE~ILTH BUREAU OF VtTILL RL'tOitDS AND HEAL?N STATtSMS ~w~te~noN tEenF~~E MED(CAI. EXAM{NER~S STA*E FKf ~ ~Ay~ NUMEER _ NUMbEt . ~ CERTtFtCATE - - - ~ U ;s U ~j L O~1' t1~ ~ . ' dty t) 2 SfX wey -fpeot~ - . ~ ~ c. , n ~i. i ~d u n ~ z L _ ? 1 p,~ w - ~ ur~~e r~ut ~e o pf,,t!( l l CfCEUED ~-ewrs(-r -r`3ors _ ~~Aocn J- n~~e~ O'R RACE ~ ~ (Q ~c` Yers ~ j . ! _ ~ ~ . . t1p5pTA1 OR (3 eo+y, w Md~l • 7. COUNiY OF ~ ' DO~i,~rM~Y`y Washfrlgtorl Hos s c~,Tn a- '~'",~1~L~ - . l O'Tt Ot IOWN [d nKOI w qWrj iaad~ dry a towa G~ne?t f. STeEEt ADDtFSS OR RT. NO. ` °fD~'"Frcderickstiurg . ~ ~'j ~ ~~t5`t"fS+~'~'shington Avenue _ _ _ ; ~couxr~ of - ; cow+rr or oct~sco•s . _ ~ _ r~oc~ ~ /'1. a L ! ,v ~ . _ ~ ~owri i~u~. tar « ror.n i~ smEr ~ooc~,u oR R. ria ' . ; ~ ~ ~vI / L. Fp Z~ o ~ ~ - _ , , _ - s e w.~f FAiKS? lt i4NDEN NAME OF ' - ; 20 3 r`, ~~~v nt ~ Z t ~ ~ ~ ~2 ~ G ~'o c r~ : ` w~„u~'co°fu~imr - ~ v. r+fva~ ~ ~oFO~ '_"e°' " . - ; Uc~ w~owfo O avos~n " Q N l ~1~ U~/J E~ S _ sJ:~u ucv Za tf verE~urr..om. «r s~. ttcrwuce (s~..~t ww~.r) rs ATE t~o! ! tr•a. _ . i -o ~3c ~w°~ ii / ~ ~ ~ - 2 - i 3 ' i ~ 4!. lUN 6I15~tiE5f RS IMFORM~NT - GR SOVRCE - r Or,tl!AT10N - IkDVSTRY OF lf¢FWhN?lON . f'~f E ~z c~,?~l ~1 ~GN E2 A~ •.~~b ~a irt~ i F~,. ~ s uuSE or cfJ~tn t~•• ony w+. mw. p.. sn. t« tAl (dl ~ l4 avrEtv~t eEmEOv ' r~rr~o~+rr+w~scwvs~can Gorona Occlusio~ °~1 AOliT ~ rw~aun a~ W t _ w • = FIL~~ • ' aueto - 5T. tUG~C ~:~1fi1 Y fLA. L - G.fwar. i! aRf..~hid~ yc.. ri.. ~ F _ ~ r~ ~ S s . . - ? ~rieti casa ~.5i, itati~p L'+~ . . }/~y~~.~/~ v L _ ~ ~ : t t . - .+.?r~p a,~ I~. C,~'E TO ' • `f i r ~ ~ a ~ = E C ~ ~ fJ / . ~Q t - /AC t OTFfft StGMRrJ1Nf CGND1tKNJ5 CONTli6U71NG TO DFATH 6llT t~tOT RE~ATFU TQ J}iE T~ ~~O _ 46a. Al7QlSYi D ~ • pSFlSE tW~L~fT10N GfirEl~t IN PAkT 1(A) ' A11iNO~Z~ - iY~ i~c t- tE~At~ wAS T?iEYF A PKFGhANCT ~tV 23c EXiEp1A1 fAUSE Of DFrTH WAS :bd. DESCNBE FtOW tHltJilf OCCU[RE4. ~a aavr~ aT~ry"~'u paA ~u pacf i~~ - ~ _ tAii ~ MOFIiMSi . - - ~ _ _ - ' T~ ~ ro Q ur~no+rn ~ PFIAMRYQ a COMiJ8Vi1tQG? - - i? Of Cy7t1Ly .(mo~) (dcy) ~J'eor) 2 [t1llRlf OCCINutED 26~ RACE OF IPUUiY (hocx, fero, 46h (etl~ or terra~ w~+e~17 (aU~ , /.til wkL nd w~h~1s F~M~. tk~d, vft"w bidp., dc) ~ . / - TJ.I ' _ ~ - er rorlr ~ C v_-k ~ - ~ i - - ~ . . riat 1 Q~ t reac:as dsacn obon, rrtv.~d d~ Eody, awd~ ~'vp and in rsp oprson decM ravld d~et - (iA'a ' MTUiAiCAVSES DEM SV'.QDE ..3UDE VND*_lERIA'1:D PfNDfNC O ? ? D O cmr oe covrrrr DATE SIGltEDi ~ ' N Fredcricks~urg 4/10/67 - ~ - - ti i?:. .~'iM0 • ,O.V 2B, MACE ~cae u~sry or aaeatory ar stve ~ . • ~.OF bt/qAL ~ . . ? a . : : ~~~2~'~n,iL 19 w ~ l~ow ~'~~,~cv ~ l~i~ - - ~ f,~~ ~ : ~ - f o~ ~ /Y~YS lJ.~E r1 ~g ~tE ^ s~i-~ s _ ' ~ ; 's~~- r~ss~ _ L - /j• - ~ vre 1• j • -~,r. ~ ~ ~4 aATE RKOc7A _ _ • ? ~ ~ E 1 ~ ' l0 ~ - T ~ ; r _ _,.Q : , - - ~ s ti. _ _ . - . ' _ ~ I ~ j ' '~t / "i'..~~ f - _ " r ~ S. > T'~ ; • ~a ` : . : it ~s..~ti ~s~ ' ~~,':~~1~;;~.~~,,;~ ~~Ufi this is a true and correct reproc~ucfiion of the originai - . . . s~~ w '-~Z- : reCqrd~~i~e:{~c{~v~th the. Bureau of Vifiai Stafiistics; Virc~inia Dep~artment of _ ~ H~tr1~ rr'`' ~chmond, Virgiria: - - - _ - ~ _ ~atP Issued ~PR 2~3~~ DEANE HUXTABLE, State Registro~ - . ANY REPRODUCTION O~_ THIS QOCUMENY t5 PROHIBITED BY STATUTE. ~ - DU NJT ACCEPT UNIESS ON SAFEN PAPER WITH iMPRESSED SEAL _ ~ . - THE BUREAU OF VITAL STATtS~tCS CLEARLY AfFfXE[~.~ Seci-ion 32-353.27, Caie of V~rginia, os Amended. -