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4/12/2012 10:29:56 AM
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004-521
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k <br />N, <br />s� <br />a(� <br />°e <br />a� <br />a <br />o� <br />Qo <br />m <br />IF3 <br />I yy <br />t 7 <br />3 � <br />�x <br />TOWN urana L s u%uu• <br />d. FULL NAME OF (If not in ho.plal or i- utntion, civa ) 'd. xw l8 ay.1. Iilw. Mtat1�1 <br />at. <br />d ROSPITAL O 1020 West Boeni <br />as !.!.""AL—' they n Hos ital <br />f. NAME 01, .. ( ) b..A ) a ( _..r. - d. DATE tdantU (DV) (Ys') . <br />DECEASED �an 32. 1984. <br />PV W) Uar C i Houser. Da Ts <br />w <br />). BEE A COLOR a IM 7. MARRIED NEVER MANNIED, R DATE OF MIRTH 1G Aga am 8 IIada 1 Ye. swan <br />) we <br />Ite YI d Wed rvoaccED t )Jan 12 18 :` <br />10.. USUAL OCCUPATION (Glw klgd of work ob. KIND OF SUSIN IL HIETH- (Cd4. iswg a awa4) ( f' <br />10. <br />wrklag R, .wo H c.W.d) USPRY Pld a a.ggttF) M!y'A`��' .. <br />De. <br />of <br />�iinel�'ome 0.0 Housaw' W o n U� <br />IL FATHER`S NATO lade MOTHERS MAIDEN NAME give NAME OF HUSBAND OR WIFE <br />arigaret Meyer . Elmer Houser. <br />is, WAS DECEASED EVES IN U. E ARMED FORCES? IL SOCIAL SRCUBIT'! 17. INVORUANT'S NAME a Sheatero • AAian <br />(Y.., na. a m)ma...)I(H fa. s1w ear a date^ of .r7/a x gorge H Hous r Grand Islam <br />1a. CAUSE G DEATH MEDICAL ciRTIIRCATION <br />= d rD—.O, <br />Ent. - 1�)O°D) � p'' I. DISEASE OR CONDITION <br />V DIRRUCLY LEADING TO DEATH' <br />U) <br />''Thb dw ...t ..an /M ANTECEDENT CAUSES DUE TO (h)...._.........._........._. . . <br />..de u . dldnr dui a ....._._..._..._._...... ._........._..._ ............_. <br />h rthala. M. "d c"Witbn., H w, giving <br />art =Dare. <br />ate. It ..u. tM rb e on the a"- .sad W dath.g <br />ear. Waq. r e.ta(tl)er th. m.4.b4w aaa Wt. DUE TO ( e).._ ....... ............................. _ ..... ._ ...... _..... ........ ...... .._. ..... ...... <br />dna <br />__.._....._ <br />It- whi h ga.ed <br />lI OTHER SIGNIFICANT CONDITIpNS <br />m W death Mt gat <br />.� <br />Co"O.w aatdhating <br />tdated a tM diwre or .:.dill.a deal\. <br />Ifs. DATE OF OP <br />19L MAJOR FINDINGS OF OPERATION <br />M. AUTOPSYT <br />TION <br />Ya ❑ No &- <br />21.. ACCIDENT (Spells) <br />2Ih. YWCE OF INJURY (e. ,Ina <br />Ihom., taaars. etreeR oH�a bids.. Nan) <br />flea (C1T! OR TOWN) (COUNTY) (STATFJ <br />(It r...nl aged. writ. RURAL) <br />SUICIDE <br />HOMICIDE <br />farm, <br />sloe ToMFR (Mmth) (Dar) (Yaar) (Hoar)).= WINJURY t -1, <br />fl/. HOW DID INJURY OOCURT <br />INJURY s Na WOaa at W7oerk ❑ <br />22.1 hereby certify that I a .�' -dn'b jpe deceaaed fray .1 -t 3 �•, 18 `.,w ..... 18. .. that I Iaet dad the de- <br />ceased alive m:._.�_".�: �., i9,,7t..; and that death occurred adA...V'.m., ftotn the forum and on the dote stated above. <br />122 SION T is (Dwee or � W �� ( <br />Wr' DATE SIGNED <br />Jr -.$ - ± <br />i seat,. itaTl)� 1 iJe. n'AME OF CEMETRB OR CSEMA?ORY( LOCATION (ptf, tows, <br />or Congo) aab) ( <br />i <br />d <br />stlz� <br />
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