HomeMy WebLinkAbout0977 STATE OF MICt~IGAN 84••162
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~ ~ CERTIFICATE OF DEATH
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OECEDENT NAME a4S~ w?at ~wst SEX OATf Of OEATN /Mu l~..~ r• ~
, Lavern Leo Wa~cner Male October 16, 1982 3
W1CE-~~~ ww w.a. ~.r.i AGE-uu Mw~r UN R 1 YEAfI N R 1 OAY MTE Oi SIRTN fMO.. D~ft Yc/ ~pUNTY Of OEATM
.~.w «r ~ lSPecrhl ~Y~A ~ o~rf •+ou~s ~~+K - -
. White s.. u s~ i s~. 1 e0ctober 22, 1921 Genesee____ _
'LOCATION Oi OEATN ~~ypf ~,T~ i~is p ~MOSMTAL OR OTNEA 1NSTITUTION-wr.r rrr..M~ r..4•~ •
/CAeet ons ~ ,
~:0~`~"~ ?'"SiOf '""`S Fl i nt ' Fl i nt Osteopathi c Hos pi tal
7e ? rw? a 7e - -
s+wrF a wi~ rrM...~ us • p1~EN oi w?ui CaM+Tnr ~ruiw[o. NEVt~ wia~to. SURVNWG SPOUSE lNwdR 9~w m~rdtn nam~l •s auaiw;
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I .~r..rrorw~rn MMOM~ED. ONOwCEO ~Sp~/W u5 ~11Mfn foKEi'
«'~~o•• s Michi an 9 U.S.A. ~o Marrie Geraldine Bar `'`~fes_
S{( y~M/A~ $OCIAL SECUR~TY MUMBER USUAL OCCUPATION (Gne RuM d work done durry matf d KINO OF BUS~NESS OR ~NWSTRY
~c~~~ work~ng 6h ~+ra~ d retw~dl
' ~3 381-18-3649 Coordi nator ~~e Auto Part Manufacturi n~
, nFS~OfNif ~i~Yi
~ CURRENT RE$~pENCf-SiATE COUNTII IOCAUTY wswt an irrrs a STREET AN~ NUMBER ,
' h,0 ~~ts ~ ~ 1290 W. Col dwater Ftoad ~
,s~ Michi an Genesee ~x i~TM~ a Mt. Morris
1 FATHER-NAME ~~~s* irwoac i~si MOTHER-MAIDEH NAME rwsi M~oat ~•s~ ~
, ,6 Leo R. Wagner Minnie E. Walterhouse ;
I ~~~µT G raldi ne C. Wagner ~~~NG AOORESS - Sr~Ett o~ ~~o ra oTV o~ ~oww slwtt `
~ `°"°:~'°"'S ,e~.rs~x~.E, ~es 1290 W. Coldwater Road Flint Michi an 48505 _
w»~cH wvF ~ 9 IMMEOUTE CAUSE /fN~ R Y ONf CAf/SF P~R L1NE fOR /aJ, ~e~. avo ra.l ° M«-• ""M' W a+"'
a ro `
i'r~• w~rcout[ PAAT 1
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,NC t•~ P ~~~?i'' f / ~ d /4 i1 o t _ ; ~ra ~ - -
'.~,T~ DUE O. OR S A CONSEWENCE OF: I~+e«.r~n.«~~,.~ww~...•.
us,sc usi ~
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L~~ IDI j~~ /cn !J / ~f' ~ Of ~ ~ - 1- /.~s
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DUE TO. OR AS C~SE~UENCE Of: ~ w«.r e.~..e~ w+« w w«~
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ro J' , f' ' r'-'~'`
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~ PMT 11 OTHER SKaNIFICANT GONDITIONS tow~~ cw•e...ro a e..rn w+ ~a ~eY1b b tw~M rw.~ ~ AUTOVSY /Speu/y YesTW~?5 CASf iERRED i0 MEDIGA:
- ~~O NO pi A1o~ I~~NEFj;OfSpec~y Yes or Aro/
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RACE OF DEATH pa.~. ~+v~.y ~w~.. i HOSP OR INST , w.e~.N oow 2ta
~~MM • I ~ I 0; Eww 1Yw . ?oN~ I ~~YI ~ ? iM c~r rw++N W ON~.w~nM .a ~0 4e ~ wr6cM ~.?~+r . <~h
~ u, o~"s ita'~h ~b In atien~` .
t.i.• ? O+ Me Msn e.a~?~o~ ~.f o. n+estqano.. n+hr ccYO~ eeHn ec~r•w a~ .
• 2~. TO IM OW 01 ~wY 4p~OQ~. MH~ O[n//W N W NM. MI M P~~ 1M O~t ~e ~/M. MN MO V~~ W 0.f ro Mf CNqfltl fltlN
w u.+et+l nswe
Z` IS9^afurcandTrtk/ ~ i ~c. «°a!~•ra..~~,.i.,: ~ - - - _ ~
DATE SIGNED lMo.. Di . Yil HO R OF DEATM ~Z DATE SIGYfO /Mo. Da?: Yr.J HOUR Of DEATM ~
u
~ 2~e /Gf/9/~ ~ ~ zs~ 11 :00 P . M W s 21b _ _ 21c - - - - -tA
~ V? NAME OF All f~NG PHVS~pAN li 07NER THAN CERT~FIER l7rpe or PnntJ ~ W PRONOUNCEO DEAO /Mo.. Day. Yi.l PRONOUNCEO DEAD (Hou~:
z3a P~ ~ r/ f~J~~C'A U Zaa ow z~e wr M
NAME AND AOURES$ OF CERTIiIER ir++vyuu~ ow r~EOita? Ex~ur++tR~ (Type a ilmt/ °
q
2s e~nrfl'il .v -~)J~pc-_t~ r~ y~_"."_- - -
•tt ~.o~r- ruru~~i DATE OF INJURY /Mo.. Oa~ Yi./ HWR Of INJURY OESCR~BE HOW MIJURY OCCURRED
d~ ?EhOU+G rNFSi ~Sivr~ryi '
26s 26b ~ 26c 260 - - - - - - - - - , - -
NJURY AT WORK PLAGE OF IN.~URY-~1 ~~On~f. IYT. Y~M. ~K~Y?. dt<~ IOCAT~ON S~~FFt Ow ~1f ~ a0 orv ~yi~ct oa ~rm~•~. v ~.r~Tf
(Speu/y res w Abl w+e~o. ISOK~M
26e 261 26g - - -
BURtAI. CREMATION. REMOVAL OTHEN CEMETERY OR CREMATORY- NAME ' IOCATION o~•. vn~~u oe i~.+wSr,?
' lSn~h/
2~, Burial 2~o Sunset Hills-Cemetery Flint, Michigan
~ ~ ~ DATE /Afo. Oa~: Yi.l NAME Of fAGL1T/ ~ ADORES$ Of FAdl1iV
Sunset Chapel 4305 Clio Road
: z~a Oct . 1982 ~e~ ~r~eral Home . Inc . ~ Zgb Fl i nt i_Mi chigan 48504
8-36b FUNER LICENSEE ~ REGISTRAR TDAfE RECf•VFD 8~ REG~STRAR 'At,- _~r.
~~~78i lS~gnatu _ /Sq~a(urel ~ ~ i Oetober 19, 1582
28c- ~..Q~ 29a ? jl / . ~29b _
STATE OF ~~IICHI ~AN : i
'~4 MAY 18 A10 :19
COU~iTY OF GF~`i~SEE . . . ~
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~ ' ~ ~ ILEG ~ „ ~ ~r ~
:
I~lichael,:~},~ C~rr~; C1erk,.of, said County of Genesee and Cler OGER PU;;
of the . Ci rcui;t Cour't for R~said "~;County, do hereby certi fy that ST. LU~tE Lu~:, '
-the foregoinq `is~a tru~~ cap~;:of the record remaining in my 6~~2
~ Off1Ce. . .f , ' , . ,
r . ,
' • 1982
~ Issued Ori _ Octob~r 20;, .
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~ ~ . , , : . ~Gl~
~ " ' .•Michael J. Car enesee County Clerk
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