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HomeMy WebLinkAbout0985 J' ~ 819634 7y ,-3 ~9 ~ Z C~ IFY ?F:,+.T Tii:S IS A TFtCc^. CQFY OF TIW C'RIGI:~AL C:.:tiIF:C::~ ' C.:~L't: ~S C' R:~IST~:t CF ~E~~S B't : , DEPVI`Y ~ A NORTH CAFtOLI.'~A DEPARTIVIENT QF Htir.lqM RESOURCES Re~istrat~on~~1V~~~ ,•l _t31VIS10N OF NEAI.TII SERVICES - VITAL RECOHDS BRANCH - o~s!~ict N~. Local Nd.~ CERTIfICATE OF DEATH TyOS, or D'i^t N~~ne of OeceaseQ ~~~s~ u'~oa~a ute Sex pJt! O~ Olat~ (MO~In, U1y, re~.! tn Dl~m~ne:l: e~ack 1. "elvin ~lair ~aucoc~ 2:Iale 3. June 1 i, 19&4 ~ Cn~or qr Race State o~ Bnth t~, ounty ul ~rsn Uate o~ B~rM Aqe n., ve,•. ~~unae• i,e~~ o~ev ?a ~I.S_'l., i~.e -l+~n••~~ ~ a~~ N:.tnJ~11 MnniY\ UJ?t NUU.I M:~. a. t,4~ite s,. `':C s~. Union 6_ i~ov. 2G, 1922 61 v~acc oi Oeatn•Coun:y C~ty or rown Ns•re o~ Noso~ta~ or inshtut•on ""~••o• Ins+ae Gty ~soeo~ rni4,E ~.e, c,n. ~ i" ..,~..nv., ~.•.r.~ r 7~.....y~., r LYTltfre~ , ~ eM.f~O , e,,~tecklenbur~ :BO.Charlotte e~, Charlotte :fe:norial Hosp. e~n atient e~Yes . . Rr,~6encc - Sta:e County Gty or town St.eet ~n4 Numper or R.F,(~, 6 BO+c No. Ins~tle C~ty llmlttt. e. 9~_ ~C 951~ecklenhura 9~. Charlotte ~9a. 3901 Arvin Dr. ~~.Yes~ G!~:eo O~ ~Ynat Countr s~~~~0, NevCr 61a•r~t<7, Su•vrv~nq Soouu (1t ~V.~e, Gwe ASa~Cen N~m!) W~do.veC, Olvo~u0 (Soecily) io. L?SA ~i. `tarried ~z_ Johnsie Hai ler Socv~ Secur~ty :~u~noe. tJSUa~ Uccupahun a=~~~ ~~~•~^v K~ntl o~ Pus~~ess o• ~naus!•y ~n o.c~ae~~ v~ . e.en .1 •lt..fOi A~mlO ~',•a~s•IYft o• Nc,r ia. 238-26-4852 laa. Self-em loved ~ac. Derit3 Auto Re air ts. Yes iatner's ~+ame MoSne.~s Ma~aen r~ame 16. Julius Baucom Ver ie Sir~nson Irtlo~mant's Name ana Aaotess - RNahon to Ueceat~0 ~s•. '~i . nsie Ba com 3 O1 Arv'r. :1ve Ch rlotte `:C ieo. tti'i ~ ~+DO~o~.m~~! In1t••• PAp7 DEA7H CAUSED Pv: fNTER ON~V ONE CauSE nrq L~~+F «~k ra b el er~..e~~~u+.~e6• i Cooditi9ons, if any (a~ Immea~ate Cau4~: Acute nyocardial ir.farction ~ 1 wRiCh aYe rise to ~mmee~ate cause ~a), ~ stating tne unae~- f iylnq cause ~ast. ~D) Oue to, o~.~ a~0~:~4~~~:~ o+: arrhythmia or pulmonary embolus I - I ~ 19. (c) Ow to, or as a conseq„ence ot: I PART tl. O!'~er S~DnlLica~t ConO~tions ContrlDuting t:: Death out not re~atetl to cause q:ven In ~a.1 1(a~. j 20a. ~ - a.,~;,o~r• re. ....e...~s.~..•.~o..ee o.u•.~..•,~t •...s• a~.~~ W~t ca~e ~ete~rt6 to MeA~ta~ f. xam~ne. o..•,,~ T~me o? Oe~tn . . t~e~-r.*~..~ - - yyyy~ 21. 21Y: WJ ri : 3~ ti. ! 10D. ' 2~t. ! ?7VOT~J'c~: StATE I.AW REQV~ft£S,TNA~ Atl. DEH iN5 OUE ?O TRAU?JIA, ACCIOENT, HOMIICIDE, SUICIOE, OR UNpER SUSP~C1n+ i ~'~JNtISUAI, OR UNNATURA~.•CtpCVM57 ANCf.S BE REPORTEO TO, AND GERTIFiEO BV A MEOiCAL EXAMINER ON A MEO~CAL' ~ AfAIIVER'S GERTIi~CAT~-OF;pEi~CfFt. ANY UEQTf~S FALLING INTO THESE CATEGORtES IS ri~i?~IN THE MED~CAI EXAMINE~ j • J'JRISb~ ~ N HEGARpLE9S66 TFIE IENGTN UF SURVIVAL !'ULIOWING TNE UNDEi~I.VING INJURV. ~ : N~r+ ' ltd~ ore~,c~~.~,~ tr;r"o~ r Pnnl? . , Atldrest . i :'j3', ~-1~'.~i ' s ,.M. . 23b. 125 Baldkin Ave. , Charlotte, ~ C. . ' S~ +~Sure ~ ~ O~te S~ynecf - Slgn wUD per• ~ ' `~Y~~ ~ ~Z.n. 730. 6=2~-8~ nfiMM b11Ck I~1k. ?3 ' ~ t ~ . ~ - - F'•u~ ffy~.ll ~ LUw , t• NJm! U~ ~ • Y or Crlmatwy locat~on i~~~~. ~o.~. w a.a....~tii ~S~at•~ ' . ' tlvsi ?tr - . t- Z~f r a~:~". 2,~.'~~ r ~84 z+C. Shr.: `Semorial PaYk z~d Charlotte, :IC .~iun~r~f -~R-{`- ..J•i,t:` ..'S19niWreoftunera~O~r~ctw Lu~nteNU. as. ~icF.wen Funeral H c, Char~ nt ~c~ _ ~b Arnol '•'oore ~ _ f~~1138 : _ - - . 819~34~ ` ~g? ? r : 21 P 2 ~16 1 a . ~ ; [ ~ ~ . 6bOK 539 Q~E 981 t„~..~~--. -