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IPHS-1551VS) REV. 1_55 NTATE OF N <br />, OCPARTNENT OF PUALIC HEALTH, ERRA9KA <br />EDUCATION AND WELPARE DEPARTMENT OF xEALTH e51, 007035 <br />Bureau of Vlt•1 Bt�ttetles <br />BIRTH NO. 128 <br />LA 1 CERTIFICATE OF DEATH AT" FILE NO bat .d lulon <br />1 PLACE OP DEATN - !12. USUAL RESIUEN(t (Where de xd 11 ed <br />• (Y)IINTY I <br />(y I� •. STATE b Cp UNTy If I llt {Ion la <br />�' b CITY IIf out 11 urpor.a II I IM RunO�c. LENCTH OF Nel)ra _.. 3 Hall ). <br />\I� TOWN Ii` !1 1 .L,tI L(? ,STAY c' ('1 OR (1f uaa rorporoa Ilml wrlto RURAL) - <br />xll d N41'IToUe UN (F (If <br />I FYrrt)t 1 n I.�Ir orl lb� IMlda(?)�vlladdrne)Ild AIII RE3S - f' ;_,I, <br />(I DATE tl0- Ix tl ) <br />*1: 9 NAME Ut' t r �' I f 1 1 <br />I E(FASri <br />II TYM 1 ) .'. -, 1 IFE (M th) ID•Y) lY ar) <br />JuL.a Urosch DF,ATxJ)1 <br />S. SEX. d (O[.OIt nr RACE 1 HARRIET NEVER NAHHIF.D. X DATE OF BIRTH, 5. A(:E (In yr•. If Und 1 Y �ff Under 3 <br />p WIIOWFD. DIVORCED (Stwclfy) <br />1 1 is _. _. �, _i_Lt IDn1'Flfri ,lEi -1h6S wt blrthd•y)I Mee. I zd xr.. <br />�. In• l 91JAL O(.t UI ATI )N ((:1 kind of work 106 E1ND OF RUSINES9 II HIHTII (City. la 69 Hour. Nln. <br />done durina moot of kl Ilfe, If _O,Q) _ <br />N FA •• " f .. r.d OR INDUSTRY PLACE) i .Ti _.. <br />TD'S �R,' '..f „t• r }, f elan 4 COUN RY1 <br />r) IS4M I2 CITI /,EN OF WHAT <br />15. FATHERS NAME I Ida. MOTHER'S MAIDEN NAME 2 t - <br />11 c rr7 !�. ^' Idb. NAME OF HUSIIAND OR WIFE <br />IS WAS DECEASED EVER F.R IN U. S. ARMEIt FORCES? I5. SOCIAL SECURITY It. INFORMANT'S NAME or 91Xn• uro `'(, }j <br />(Ye r unkn (If yea, tive war or daM f ervlre) <br />(`. O NO I Add <br />E �E;�AUSEo OF " " fEATk, <br />MEDICAL CERTIFICAON <br />)SW{I� (F�.Cl r3 <br />I, TI d M�,. t. DISEASE OR CONDITION Inan•1 He`-a• <br />p )IRECTLY LEADING TO DEATH• Oneet as •Ih . <br />•Trl•doe•notm lh ANTECEDENT C.1 USES - <br />otle of d >Ins. . h <br />4 revs f•Ilere, th i M rbN DUE TO Ib)... <br />� ti It mean• th dI rnndltlone, If •n >, ttrint <br />ve, Inly >, or rem 11 w to Ire •bore r•v (•) �•... <br />tlon he vnderl >Int r•o•e 1 •aOnt <br />V • �, whleh eau.rd d th DUB: TO (rl <br />�$ IF OTHER SIGNIFICANT CONDITIONS - <br />w 2 1Z r� �• condmon. rontr�euun <br />.DA f1 n e1•ted a the NDIN dl l n TIOnt death. , C'Jr). ,, _%, •, /J /� <br />O 15e. DATE `O OPERA 56. MAJOR t'INDIN(S OF OPERATION 'f" /wjVl t_/ 72 AL , <br />$ TION <br />E eo. AUTOPSY7 <br />ACCII E 21 •. SUICI ENT IS_Oy)- 'h Ib PLACE F INJURY feu, In Yee N. <br />E SUICIDE etree[, noire bldar, r. (If TurnlH fON'NI (COUNTY) ISTATE) <br />HOMICIDE, <br />-Id. TIME (Month) (Der) (Year) Iltour). er e. ware RUAA AL) <br />J 21 e. INJURY OCCURRED _If. 1101 DTI) INJURY OCCCH:' <br />IN W IN et Work -- <br />m. Not 14il Work 0 ' <br />"2. 1 h by certify that J att— dl,d/thc dcccased ra J r�, to.. _ -- <br />eeas 19.S.T, and that death occurred alQ 3t!yp' ' -9 - 79'� thpt I last saw the de- <br />:5•. St ORE +. )rnn th carwca and an the dal stated above. 2�. DATE SIGNED <br />5 Ikur.c or title) _ I r ItF - _ <br />CREMATION 2iu. DATq, L/ t AMF: ' }t' t FMEfERY UA I.ItEMATORY 2 /d. LOCAT'pN� `Cltr. tow ,for rountr) (Sate) <br />/�R�E�MOVAL 1 r.Y . <br />r,•M_ 1iG 2 1 JJ t HEGIIT7{AA'S v)GNAT 1 . •.. <br />--F/ f/r /y'J '' FU \EItAI 1112EtTU1tS SIUNATUAE <br />_ _af.I Al- �lL_ �a� L <br />171n, ... } ?: —.ei ADDRESS <br />
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