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<br />DLP F Or TORLC t3ALTR. D
<br />EDUCATION AND WE.rALi
<br />RIM No. 126 ...--- CRIMPICATE OF DEATH
<br />eFATL sns Ya
<br />y I. PLACE 0 ■
<br />r- COUNTY s. 7RATL
<br />X
<br />• hMMearhtlnl.:
<br />1 • C tH e b t•.wrlu BvgO o. L NaTY Or . lu
<br />STAY
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<br />i 6 PUL9tL�YNAYL O► (If sot iq kaWIW v tgMAWa, Blw wtwt
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<br />d HYRLRT
<br />- (H ragl elw Yegliw)
<br />i INttORYi imON r CA d ; cwt
<br />ADDSS88
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<br />L DA�� . Irirw/ t 1 ) r
<br />•
<br />- e. DATE Ihla1 ►) (Doo (riv)-
<br />ar Print) L 1 S l /
<br />DiATH f
<br />6. t1YE A COLOR er HACB T. YAARIEI, NWER YABRIW. A DA'[i OF BIR'[N
<br />W WLD. DIVO W I-51,)
<br />f. ACL (1�Ta tUMrgT �f q��
<br />IYtM
<br />E41 /f/ /7/P/6 NH,,;A
<br />!n }• ,
<br />k VeUAL OCCUPATION (G1- Yod of wmk IOA L1ND Or INDUSTRY 11. BIATII- (Clb.
<br />daw earl N worWee 1 w.q H reUtedl OR INDU81'RY (
<br />bwn ar <oqe lBtW it CIYTZE o WRAT:
<br />m f_ aom )
<br />.
<br />F N
<br />li. FATHER'S NAME 11w MOTUNW1 MAIDEN IIAYL N6 NAME ND OR WIFE
<br />S1MES JS
<br />i
<br />16. WAS DECBABED EVER IN U. A AAYLD RO t U. 80CIAL fIiCURl'1'Y lt. ►OEMA AYL 81wty+ • ANtfm
<br />wkw.gi at yeA dm wM to
<br />is. CAUSE Or DEATR
<br />Eg4r only we uw am
<br />NWICAL 1ES1MCA N
<br />L DISEASE OR CONDITION
<br />/-
<br />ff� DNIB
<br />MI Ilw for IU. (bl. egd(e)
<br />DIRRCI'LY LEADING TO DBATX• A1�'` // ����/ //
<br />/
<br />�/
<br />•TYr dw aM mw the
<br />na4 of ylne, eqA r
<br />ANTECEDENT CAUSES ✓
<br />OUR TO (b) . ......... ... _ ...... __ ...
<br />�._.__
<br />' I Yeett fallen, eetMele.
<br />ate. it mrw tM db-
<br />YxkY mNtbee. U us. fl<IgE
<br />u W ire aew (e) e4tlw
<br />.f ew, la)ery, w mmflke-
<br />Ibn wkW eewN iLL
<br />rN
<br />tY uMrbbe segrr IW. DUL TO ( <I........._..._. ........_....._....._....._...........
<br />._...._.._..._:...._.._....__..
<br />.._ - -- -- —•_. _
<br />� •
<br />o4 2 II ^ •
<br />11. OTHER SIGNIFICANT
<br />n4W a CONDITIONS
<br />ce""— Y the 4wt N mot
<br />aMlllr <eeeW dwLL
<br />19e. DATE OR OPERA-1
<br />TION,
<br />- - -_—
<br />1eb. MAJOR FINDINGS OF OPERATION
<br />20. AUTOPBTT,
<br />i
<br />Y. C] Me I-'
<br />21o. ACCIDENT (S -111)
<br />HOMICIDE
<br />= (CITY OR
<br />TWN I AURAIW OVNTYI (STATE)
<br />214. TIIMFE (Month) (DO) (Yr ) (Houe)
<br />INJURY m,
<br />Y1aW,61M et UR CC
<br />Wmk
<br />Not Whit, at Wwk0
<br />21f. HOW DID
<br />INJURY OCCUR?
<br />F
<br />1 22.1 hereby eargJy.�jjhat f att the deceased ITOm.ts�... -. .., 18w't ..., to. ..-
<br />•
<br />.,v�,,,,L..., 1P'��i.., that I list. 80W the dep
<br />1 ceased alive oN:.:: , 11,5W, .d that dgath occurred at..(. ., Imm the mwes and on the date stated a0aea.
<br />2. AIGNA•TURE �/ I ) lath. RE88
<br />Yie. DATE
<br />M
<br />ANA
<br />_
<br />RNA BURIAL yI' ��N6. DAA'E I 6 OF ERY OR CR AT'ORY
<br />gI�REOVL ❑Ir �f.1l 4La.L�iL,_ %y__ -_LL -'
<br />2dd. LOCATION (Clp, towq, m <amty) IRtWI
<br />_ !/•177
<br />,
<br />93
<br />I�lllj c�c t7 tFI6: 1111 -�n H<S }I IL T(�H(C
<br />C�:I�,,y'I1,) A'I':1; UN F11)4. �1•�Tf;J THE S'I
<br />VY "CAI /S"i'JA- 1- lS,1ICS, WMCff
<br />tt3R tf
<br />cIN�AtN; rJft(kr.: ,
<br />A "I]tI1: COPY OF An OkIGINAI,
<br />A Ch: l)I:I'Ah "1'1N1F:N "C OF IIf:AL1'Ii,
<br />Ii "flit' IJIGAL DEPOSITORY
<br />.ti ,. _ A I tiIA .f
<br />1 8101
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<br />-caffi of N° J,r.-vka
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<br />i
<br />5
<br />Fees
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<br />,
<br />93
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