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4/12/2012 10:56:50 AM
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004-071
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NMEVASK& (6tATD) ONPAXTMZNT OP' <br />)]aBw tIt Will AWr1b <br />STANDARD CERTIFICATE OF DEATH <br />U.� , ��i � G 39 <br />N.tfaW Dm w at Yfw m.efww <br />S.W S-4ty No..... ....... .................__._.._.____.. State File No._.._- ._...- ..._.... .... <br />1. FWCi OF DH <br />87$y S. USUAL RBBIDXNCB OF DLCEA=D: <br />c m4 ._—_ _1_.i.. _._._... i.) Stw..._.tishrkska._._ -_ (b) C—t,. <br />z! la Q4,,,,w. —. Gran3Y7sTanc! a <br />n�(r) N... at (N .Aide eW «cows a I4, wr14 RURAL) t.> ta4 m eo.r f - W6Sd1j, - l!AYlSL_._.._ <br />horpR.i or lvWlotbni fit wtsids s,4 or alt." wr14 RURAL) - <br />s <br />61h .. <br />3 IN a..t b bwplW or I.ai n L— wr14 ar.ec o - or for ibn) (i! rar�l .Iw bo.tbn) <br />(d) lomth of slay: In bospi4l ,n.Utotfov. .. 1 - , J <br />.._ --._ S ye_. (•1 t fonlev bore how 1 in U. a A. <br />In this com.ni4.._ ars. <br />t_ ..._._.._........_..._..__y..rG <br />(St ltY hetM n+. nwr., or dgr) — IMICAL MRTIFICATION <br />zo. Data of d..lh: <br />SlD_NLL NA <br />YR Eiary. R Rodrigues__.. <br />albj It raeu _ <br />.. =-- zl. I haebr ow44 that I�t7t Ur i <br />. roe<_ <br />ums wsr _ _....._...._.— <br />— ....... . <br />__- 7 <br />I <br />m 14jiAi r 4dif <br />s. fabr or 6U) v.M. - wldow.d, mar- that.1 4.t. r. ....Ilw ... <br />and <br />t. « ..... l - rid di—d marrie,l U ot death arr.d <br />mm <br />d.. -- _.V. .. f�•e•' <br />6(b) Nsms of h..b. d r wit. ..._. .l.) Age .1 hmb.ed a ._. ._._..._._ <br />Julius Rl)drigue z all. N .ffw 52.,r. ... ....... ... <br />_sass_.............. <br />9. Bill data of dree..rd ._.-. ._._.._.__.1Q..._._._�,g _� Dan b ... .._ <br />e i (Dla ftr�..5 <br />Oii Ys.n mmtb. Dy. It Vd th.o ow - -` - -- <br />4 7 2 18 ............ . _. <br />p • Other so: dill..—.:_._.—..,._. ._.....___._..__..-- -._._..____ <br />e. Blrthef.ae_ Ruoir.,F_a_n D.a_....._:....._ _�.4.1.4T. .d.9..____..._. finaloM Owe.:oq wlthl. a tmnw o[ d.aN) PHYSICIAN <br />(CIV. <br />House fe _..__............ _s_.._. <br />,6. U.s., orwgtfm _. ------ ._....._.-.._ I'......__ x......__. .._......_.........._....__..._ d.iar tivEbp: _. _. —� UndaDw <br />n.,ndowY or bav—ti. o.; 5e........ ....... ................ ..... ....._..._.................._.. of m.r.nnn. _ .............. _..._.._.........:.. ...._........ ..... _- _........... u» ns. m <br />whiz d..th <br />,a N.mG...._...._:. J. seta... Sales.,.._ ........... ...............__.............. — — ..._............_............... ....................... .... .,_.:..........__..._.. :"d b. <br />L wnhn,.m........ o....Rec.c.rd_ L4oxr .c.a......_.._..... of .v op,r ...._..._ ................ ..............._............... <br />- ..ys,�U. tlafr.W <br />1 ILY4, town 4i- (eta for 1 ml ........ . ........ .._I _ <br />......Lugarda Y.alde�, ............. <br />u. Blrthpf.... .. N o, $e r o x �.�... _ _G. o �:.4 Fad 9...... aa. u dash w.. dm in ad r..I a o.w. DD m w ty)kw,oe <br />(city' <br />bwv J 42 1544 (or.lFn rw vY) l.) AxldsnG w1oNG or hmi<Ids�{.D.slf7) ✓ - <br />16. a) Informant awv de..bw l}, 111s_ RoCl_ri f'ueZ,_ (b) 1>•4 of oce.rma_....— ✓J,.... _ <br />(B -L.I. m crane Islaga °� oeblr�........ (o)wb.r. did fw. r naitilegofat4w )— _acs,1. , aiwtai <br />17. (a) PlaEnr1$1 sass b) Da. thu.of 7 1 4II .r r..... <br />E SBOrlai. «.m.0 r.mora� a eh) Y 1 (d) Did Wort orwr b .bee home. m f In f do.GW v,.s. b I, <br />' s)F4os:ber41 Gran9 II °ian e r <br />( aU 1 <br />f la• (.) men.tn o<f.3.Sn�w�sko.a 5anciermann, / <br />k (b) Addr Grp Islrzn x Ne„ asks <br />,vhlb <br />aa.. m Lt ... .. _ _ _ _._..__. MA d r <br />of .Ih _ <br />��4r:... _ A Data .d I <br />71 <br />ii <br />I <br />( <br />71 <br />
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