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HomeMy WebLinkAbout1609 1 ~ . ~ i - ~ - ~ i ~ ~ . . . j f . - - - _ • . . . - - . _ ~ _ ~ ~ EXHIBIT A ~ ~ MINNESOTA DEP~RTM~N1 OF HEAITH ' ~ , ~ Srsti4~ aI Vi1~1 SWi~tia ` . . ~ ~ C~~tl'I~ICATE OF CEA7H " ~ ~ .o~.~ ~ 3 - . ~ :Tar~ r~t[ ~u~rsu ~~r)f ~ w.~~0~[ ~ ~afr _ .`a. 1.D[CL~SlO~NAME l•~E~ ~.OATE O~ OEATN . '~~~K :t. ~ ~~lilli~ E~rt 24a1e Au.~,~ust 18 19?Z~) ~ 11~ r(Y!<~ST , ~...~~_._'L.~.,~~.~~~~ . t~.AOt .~~U.~+DfiOrrETExlru.utiOE~CNEO~rii.pwiE O~ NitM ~+ow~~ o~• rt~• •.RACt a~ct~~i lo.C0llNiTOfDEAtH •~;r~o~~~ s ~a o~.s -ows .•~,u*cs = 67 ~ Sept. 24, 19~5 C~uczsian .R~r..se~ • _ ~ - - 70.~OCAt1W~i0~ OtAiN ' ~~~~~•Y~~ - ~.s c~~~ yu~w~~~.•..~+ 7d.MOSRTAI C~ O(Mtt INSiiTti~fOH-?iwMF ~~r ~1* ~~t~r.c~, cn~' • :.3 . . • • . : S~~t[T aw0 wVwaC~~ . . = St•p?ul' Yes ~ Miller Hos~it?1 iRiMKAC[ ~a~~rc a~ ro~t~~+~ tOuH*~*~9.COUN1~ iw?~AT lO.WtOOrifO O~vORCEO~tOctvr ~~'StQYi~ NAME ~ - St~aaul, i•t~r..~esota II. S.A. ~ I•i2rried - IC~treri-te ' .t 12.WASDECfASEOEvER~+YU.S. 1~.SOCiAI:ECYtI1TNyM~ll ~a~.U1UA~OCCU?ATION iG~vt~v.oor~oe~ ae.r;~Nr)OftUSiNFS1Ot~NOUSttr Au~AEO/ORCli •MC•.. .a. r.~ DuRt?iC NOft 01 n0~~~~4 lK[. crc« r wcTU o~ ~ t'o 701-10-$~74-1 Accountin~ Cle=~: fi.iT. ~ 3ai1~-~a.y Co. f is..tes~awei - sr~ie isw eounn ~s~zrst.vut~eE~ Se.-~;.°.~:=;;•t,._•. : - ~ . . . Yes ~ Min,.*~e~ot~ - . Ra..~se Roseville 11w~Afl1l~~NAME 1~?,p;iM/lAGE ~s~~«~~o~cw 17.AOO~tSf Of OEC[OENi a*~eet awo ~vu~~w sost o~~~cc _ cnvwr~~! ? ~i'iI-.~'`-t"~@3 trc~"~ - Mj.I1116SOf.c1 9~5 Ti~. ~].1~1•r/2V~~ ~~.'~.~~ll~ . t:L'~.~?. ~ 'f 1i~.MOiMl4-M~~OFe~ h.~t+f ~ swi+ATr+?I~CE~ar.~EOwrow~~e 9,~N~QtMAlIT-+vwnnE ~aowess ' COYMf11T ) ~ ' . N 21or~ J. iJOrdsiro~ Miz+x.esata 1•Lrs. ~/ilZi~ A. H~rt, 9~g t.;, v; ~ ZO.RAtT 1- OEAiM WAS GAYSED 1ENIER OHI: Onf CwUSE PER UNE Ik~, t!~ ANO IGII li pACryCS~SOiFE~IEO ~•DO°u•~+•a:~:~-fa,_~ - A.IMMEOIAff CRUSE cMCC• 6c• •[*w(L~OAS(T Ay) - i• - ' . ~ D[AiM ~ - ~ ) ~ n _ - - . _ ~ - l••~ ~ - t R 04! TO. O~t wi A ' ' • = ~I CONSEGUENGE Of p~ ~ V . f LEa ~li COUN?'~R~~~ . - _ ~ ~ ~ c.ouc ro. oR ,,s w ~ c~ea~ c~qcu~t cou~T _ 3101'~$ ~ eoNSeouENCF or R~~~Rr Y~hiF1ED _ " ` ~ • ; Z?Ai~ ~ OTFIEt SIGNI/tCAMT CONDIilONS _ _ e.AYTO~SY 210. ~~..t..n~..o.rsc.y..uMO i ~ O ~ a~cu~T tc~cw au~r,.....c u~s~ w o..~+ ~ r l~c5ry._. ~ ~ 5 - No j . ~ ' ~??aAtClOtNt, SUICIOt, MOI`+HGIOEO~ UNOETERnnINED ~2~OnTE OFl1~1lURt MON1M owr rt~R ~ Mou~ c•~NJUitT AT wORR s?[c~r• res on ~o ~ V a?ccrtr : ~ tF O[fERREO - . CMtCR 10• ~ p.: i~ M" ?.,..fIACEOfIPIJUMI~T~O+~C,/a~?~,ST11[Ct,iKip1~.0/l~Ct ?Z~.<OCAj1~P1 STIIC[TOr1AfO MtIMtE• C(rf.YltU~G[CATpWA3wt1 CClU~ti ST~T~ ' W - ~ •VKD~Mi [TCJ ' _ . . . . . ; ' ~ ~ - ~ - ~ ' ~ I24 MOW 1NJUAT OCCURREO - «+~TtR w~TU~c or ~Nn~* ~n rw~t ~ ow ~wwr 11 , ~T[~ 20~ - ~ J . _ ~ . • . ~ , U ~ 27~.G[~TIIICATIOH- IMTSICIAN •~y ]b.~(RilliCAT101i - M[Ot[A~ EIAM~NER OR COtONFt - ~ 1 Mt•dad ~1+• deew~ed h~an _W en! On tAf ~et~a ~f tRe ~~om>~ohaw ol tM bady and/or t~e i~r~~e.ye~on, in en~ op~n~an dtatk ~ ..a. . .c.~ . - I~al aa.. MinJAe~ -e6.• ew . t160. did we! ~~s b~d~ dMv deal. acev~ed ~1 /~w, oneA ~dert ewd dr~ ~e iA~ cwie s~ia~d o~e.c. T n. e~c.~e~i Oe~fM ~ccwr~ e~ ~ M a tAa p!x e ewJ bn~ ~xd ~w ~A~ ~sM ua~ef H~v~ ~nd lo wos yr~w~vwc~d f eed an ~ •a u ot M. - - 1A .e1n~~kwowiedq.JuaSaH~stovfrf ~~ael.~~ - - ~ ~2 t?M~StC . - S~G?v fU ~~tts )d.MiWCAL lfA :S!!!f! Qt CO~OKfR ~_StGNATUIE~ ~ ~ ~ ~i.~ ~ • y ~ _ ' -~y~-. 27t.? ~ r~AME 'T*~t c~ o~~» ~f.MfOIC~L ER~t~ttNERORCORUr~Ft--NnME -~T~~~ oR PR~~iI w K~ I11 ~JQfI ~ R~ ~J S . _ , - r ~ 7]p.MwlUivG AOCIlESS Dw1S~C1? . MCOICAL ca~..~..cw ow cowow[~ 23u.pAfE StG`~ED ' MO~tw OA? - ' ~`~I;~ T G'~lZ^t ;:E.'^ i Cc:l : Z`}'..~~ !i ~ ~ ~.p?tl:. ~ i•i1TLT1. ~~~.~2 .-~iU Cn ~.n~3 - t t' 2~• ~Ut~A~,~~EM/~r10M,1[MOVAi :a~CfMlI(2t01~CtEM1lTOtY-VAME itt.IOCATtCN ~C~."*:~~~t~G[ --~s..~'~ ~s'.r[. ~ ~?t[~?~ . . G Buri~l ~orest ~,~~m s•ie^orza? ~'_c t•?~~1e:•:oa~: ~ t;ir~esat~ ! 2~I.O~fFO~1Ui1A4C~2EMw710NCf ~?S~aiUNEtA~M~MI~~NAMR ~ZSS.FUNERAIHOME-•DOAESS ~ ` RfMWVAI +~C•:~ niT r[aw 1- ~ y - ~ - _ , ~ A ..p1+_ a ~d0~ liiC.C.Cif. .l4• J4 P n~~ ~~r11:~ 1 - ?Z, L : _.n~~rso:~ ?1L..,_al _.o~'"~• ' , . aul, ?u+n. •~-OAtEiitE01~ tOCaIREt:i;itA~ A~ lEGIStiAi- S:G+iAiUIE _ 7. 1,tpyitClAN t1R f~fNElAL OItECT~J!- ItGNAIUif ~ GCw-. T ~~a• ~ ' i r I i AU 2 3 t~';3 - ~'J , C;~ ~ ~ ~ ~ ~ ~C / ~ ' `~--f~ l i' 1 ~ L./ 7 - ~ - ' / ' ~??.Tfl1Q C• Fsi1Qe~~~,"~ ~ • ' - " • _ - ~ . • f . . 3 - ' • _ - , • t . . ~ ` } ~ - ~ ~ ~ ~ • ~ eaox ~~0 ~16~$ _ - ~ 3• - ~r - -