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HomeMy WebLinkAbout0395 t ~ - M ~ ~ ' t - - ~ • _ _ _ _ _ ~ - ~ ' ~~f~.~~.',8 ~ 'r - . c. r..42J,2 ~E 92'7 ~ ~ - „r.•~- CER i IFiCAT~ OF DEATH ` Oie/+~twewl e~ t~If` ~ ReVblIil~Hve ~Ic~ _ - iTAT[ R~t~ Na,. ` a~~~~.TM F1.OaID1~ s~~~rne~amrwas RtGILTiUlR•f HO. - . ~ OECEASf6-NAME ~ 1~t1t . . . r~00~! . . . ~ t SEX DATE Of OEATM ~ rcwi~, a.~, .e.y _ ~ ~n - ~ a r~ ~ ~ Dou hertv r. ~ A ril 14 -1975 ~ ~m rr± 11/M!}}. M10W. ~rl~KAM IM04M~ A~-~t~~f 1~t v~ote ~ e~r UAtE Oi NR1H a~. COUl~ITY OF~D~ATH . . - ~ ~w ~ ~ ~ - - ~ - - ~y ~ G~ "~'1 r eu. ~ s?ttar ~ f~~nan: ~ tu~s~ +~of. e.y NOWf rw. ~.t n t+t , rJ ~ . ~ k. ~ : ' ell.a ~ ~ ~ <<°= ~ CIT'If. TOwN. OR tdUi10N Of DEATtt Muee cm ~w~et HOSMTAI OR O~tk'R tJSS ION-N ~n ao~ ~N ert~e~, crr~ u~ee~ ..o ..w~ce~ ~ in~ p 4~" s?et•~r nt oa wo . !'lpa ~ra ~ •a Co t - D ~ A ~ o~'~~~`~, -ar- ' . STA~E Of N'df.i ~ u~ot ra v.s.w., nu~t CIT12fH Of MRLAT COVF(TRY MA~RffO. NE~?ER N4~.RRIED. SVRVN SKNJSE ~ N r~M. ont ?v,wt++ ~.?rt ~J a' ~ci~ r~~ - t~ncsar ? - WIDGWEO. [1MOtCfO ~ fntrr ~ . ` _ ~ 7~ ~ ~ o ~ ~ lli o3. - - . - arried t? Lill.i~n 5cott i SOCW SECVRITY NUMwE~t . USVAI OCCWATK~N ~on~ crao o~ v~ou oowe ow~HO ros~ w KMJC O? ~11SM1ES5 ~ IIdOUSTRY -^t i .ro.a~w ~Me, eY[~ n nnro ~ . - . ~ , _ ~ . ~t : 376-1Q- 6 ~ - Police Se eant ~ ~ I3etr~it Po].ice ~1eo~.rtT,en~__~ ` RESIOENCE-SfAfE COtiNT1l CITY, TONM, OR LOtJ?TIOPI '~'swe cn* urm ST#ET AHO NU~?UE! _ - ~s?ecux ns w .~o~ ~w~ M o d ~w. P R21a ~ u~ ~fo ~a2 62 i3razilia L'r. - ; ~ fATNfR-K~ME . r~nr _ . r~0a~ . . ~ Vtaa~ AiOTHE!-MAIDfN NAME nesi ~ ~ .ucar ~ . . ~.s• _ 1 ~ ~s Frank Dou hert - ~E. _ ~ ~ertha ~ Stpvens INlORMANT-NAME _ MALING AOURE55 isteitr ot ~.t o. ra. cm a~or..., sr•r~, zr~ - ~ v~ Mrs. Lillian nou ert ~n 2~62 ~razilia Dr. A t?2 Glsar~~tsr •Fla: 33515 ?ART i. pEi11!1 WAS UVSEC ~Y: (ENif! f)MtY O.YE UUSf tER lkJf fOR (o). (bJ. ~~1 l~/I _ ~itwtE~ o«tin ~.w oe?rw - t1. - rueounc.us~ - --fi~-- t•~ Occlusive Coronar Arter ~isease ears „ „ ~ : - _ • ~i ' . . ' _ . _ ~~YY.~l~ . . ~ CQMDifIONf. 1t LM, . " - ' _ ~ ( _ . - ' wM~[w Gwvf ¦~3! t0 (b) ~ M6~ ~i~r y_ . . ' 3 ~ ~~rtp~~tt C~v3! 1a1, p~C t0. q ~S a GONuOVtrKI O~: . CL~[~P S ~ - - ` - i _ ~ ~fItING 1M[ YND!!- . . . ~ . _ • ~r~MO e.use „s~ . _ - ~ [ci - . -1 I [ € - IART li OTHER SK,NIFICANT CONORICNS: co~wroa+t ce.ne~~ut~.ro +e w.n~ ~u~ ~o~ nureo ~o c.usi enew r , 1F rE5 we~[ ~~»o~wes ca+- - - - :.es w~o~ S~D~!!D fM DlitN~~1iMG C~Y1! ~ _ . _ - ~ . . _ o~ o[~rM j t . ~M no ~w - - t . ~ ~ ACCWEHt SU~ ~E R ~ra.n., wr, ,e~u NUUR HOW IN)UR1f O:CURRED t(M[~ N~TVff OF INIV~i u+ r,n ~ p ratt n,'rttr us • y . ~ IqMKi6E: Ot UNO~iEN1111~D - - - - - - - ~ . ~M tN. ~ tec. - lrt. 7M - . . ' • • ~ tNJVlY AT WORK - P1J?CE Of td1l~Y.~ No~.[. ~aw, sr~r, ~.cron. IOCAflON ~ sn[~i oa a r.o. ~o , cm or ~o.~a, s~.~e ~ - _ { ~ ~ WC~/Y 7f1 Ot MOI OMK! MDG.,tK. '~i?KMr~ . - . - ~ - _ ~ ~ . ~ . _ ~ . ~ . . - . ~ - . ~ . ~ . . . . ~ . _ ~ . ~ . ~ ~ . ~ . - ~ - ~ rpMtN yr rt~e - - nOw1M- ~ D~~ •f~~ ~ 41t L~w Hw~He~ attv[-Ori ~ Or0/C~p wOi nM 1+H OfAiN OCCU!!EO .~t mt ~u[t, Or~ nK . . ~ ~ ' ?Mt11C1AH: ' ~ - ~ ~ Tp ~ . _ _ ~-rOwM D~t tt~~ ~OOi ~rttt Ot~tr. ~wOVt~ Oa~l. ~?W w n+t rsr ; - - rr I[~K'rttOGt, uu[ ~ ~ .*t[NO[~ tye .o rne uvse~s~ s~.rto ~i 21a J[C~aStD /tOM ' ' !1?. tlt 71/ Zit M ' CERTffiCJ?TION-MEDfCAI EXUiUNER OR CORONfR oH *M[ s~s~s w.r~[ Nou~ o~ at•n~ tNt OE[lD~NT v~~3 ~~O.eOVHCtD Dt~D - lurw.ra.. rnt wo~ eNC/oe rKt urresrwaro«. +H ur O?w~Or.. ru++*N o~• r[.~ w~u~ - ou~~ «eaeeeo w n+e o.n w.+n ou ro ~~e c~vi:~s~ s~.rto. µ tt? A ril 14 M 'h ' - .-$t-4~-~- - -~------•~7 : 50A CERTI'IER-NM+~f ~*trt O~ ~t,nn _ , ~ATURE otce[t oa *rt.[ D~?TE SIGNEO ~ x*M. o•...tw+: :s. i Assoc.Med.Examiner rk -April 15,1975 MAIIlfG_AOO~ESS-tERTtfJER - snet~ w o. r~o. e~n w ec..~ s+a-[ _ ' - } - . Lro - wa~t. c~~u?tior+. ~~+ov~i cE,?~rew oR c~~v?ro~nr-r~ ioc~nor+ o~ o. ro..,. s~.n ~ frturt ~ • . t~ R m al ` _~N Q~k Hill e e - Taylorville, Illinois . _ [1ATE ~ro.rtM. o~r, rt?~~ ~ fUMFtAI HOtAE-NAMF ANQ AOOtESS ~ s~nct or ~ ~.o. ..o , cm M ro~ Ry~~rt. t~~:P- h+ 1 ts. Jenne Funerai e 2 10 Sunset Pt. d. CLaraatzr, r^ la. f - TURE . . - . . ~ REGIS AfURE r ' OAi~E CE ~ D ~Y GOf~I REGi t~f : . ni- S - -/5~,~~ ' ~~R f ~L- " ~GG 'S'i'~ _ - ~ ~ Q j fi~ : . _ . - ~ _ ; - A~( F R'~ ~'y7~,r aCARRY TF:E EI~' OSSED SE:AL OF THE REGISTRAR ON Vi~Au~ STA1'1 ST1 CS = . - _ Y~i^' `a. ~ J . . . _ . . _ . . . . - ~ . . . . _ ~ ' ~ ~ . =1y-~~ t ~~~,lr-.' ' . ' . . . ' ~ • ~ , _ _ - - . . ' ~'~.o - ,~l1~ v. y~,f,. ~ ~ . . ~ ~ . ' ~ t ~~x t _ . ~ ~ . _ f~. ~~~.'~I~eli~ll4~rtify that this is a true_ and correct copy- af a certificat~ ~ ~ ~ ~ ~~'~~~ttie office of rh~ Local Registrar o£ Vital_Statistics oC~ihe - " , ~ s f~ rf~ . _ - ~~1- ` Co~nt Health Oe artment St. Pet2rsbur.g; Florida. y ~ ' ~ . ,:•f ; - . ~ - - 4 - _ - . ~ ` ci Fj r ' ~ - De uty Local Registraj ~ P ~ ~ , tt~ • '~~~~5~ . - . ~ - - ; - - _ . - . OOK _ PAGE_ " . ; - . - _ _ - - - - - - - - - _ _ . . ~ j ~ET11RN T! - - ~ ~ 6EE_4LES, 6RACY~ fREE60Rf! i FR111ER, P. A. - P. 0. SOX t039 3~~, L~ . - y': ~ - _ Q~'NEONI. FL4RIDA " _ - ~ - - _