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s�o <br />PUE736 E0(IUL' E�ERVI�OE� .DEW MAW <br />ABTMMW OF IaAU18 • <br />BUMM of "tal atallMlo. <br />l`mII(' eklm OF DEATH. ..... <br />1 <br />Issued June 14, 1957 <br />'n <br />$ A 02t : �,,,. a watka ADDREC/ <br />'� • <br />na <br />w O tt»Yi< maw) , <br />oe Prlai) <br />.0 <br />0.. or ills z. <br />D T I <br />RDlTt Al" tt Q <br />C ' <br />D..l <br />.. <br />10a.. USUAL OCOUI -*nON -(Giw load of : woe IOh. FIND OP BUSix !I. <br />(pq ' ee li. Wmlr <br />7 <br />d emu of errs U <br />doer o[wroiciaP 4 a•tiM) Qa y' <br />U. P. 'B NAitJd iN. Y M YAIDEtf MAJOR <br />xN, p! <br />�' t <br />;. <br />,Mw <br />.: <br />q <br />6. ;rA WBO&SM EVER V. ft. A811ED ItCEB't (0. BOOfAL <br />A. <br />E1:YE rs ♦ AddNOi <br />..$ <br />(Ya. tr ttnhnown) iIt'tes, slre war or daW d � <br />•f <br />� �al <br />t &.CAUSE OP nSAT$ r ffiBDiOAL Ol16TIPi�TiON <br />W'Ceew j <br />e <br />Eater oalt tats NW <br />Ueo for (�. L. DDYaH4T�LY�LI0A TO <br />. <br />DAATIYr <br />-Tbb dw ra mmm W ' :ANTECRUTIT CAUMS <br />modaot dtlaa,. sad DU! To (h <br />,e� <br />I1,g�Y> <br />toUeto, rtAralo. ttxhM aadttlau Naar,. debar , <br />e. It arw W :tbe N W ahrrot`aaN W Nawai <br />. <br />ease lelan, K aamDl W ttalsrlfiar ,aaN brat DUE TO 2 (e <br />tMi erLe► oared dr <br />11. OTHAR SIGNIFICANT CONDITIONS <br />•OPT <br />Conditions a trUatlat -to W dwth haf net <br />lated to the dl w sr readlas ,asalne drag. <br />i Fm <br />19a. DATE <br />N <br />IM IWOR FINDINGS OF OPMRATION <br />30. AUTOPSY1 <br />I,t <br />s1a. ACCIDENT (99rdit) 11h. PLACE OF INJURY (e.r.� la ae <br />SUICIDE �hnms, term. tadmr, <br />,. <br />91e. (tCITY o9 Towx) MUM) (STATE) <br />tdreeq tdnar hMr., oa,) <br />HOMICIDE <br />lIf <br />carol oteU. wrka RURAL) <br />d <br />B <br />fld.TIME. (M-dt) (Dar) (Year) -(HOW) <br />OP <br />I ri INJURY OOC <br />21t. How DID DUMT OCCURS <br />-. ;I <br />i' <br />INIURY ml <br />Nae while u Wteeh g <br />I g <br />A <br />21.1 hereby certify that t attended the deceased /ram.... <br />cetiaed �tlSe..... 18 .1 and that death 000wrnd at .A : <br />4 ._...__,18.x, titdit I teat sOto the de .i <br />I, ITOM the caaaso atld on the date #Wed abom <br />pp <br />(Ihtitae <br />U. SI tklo) <br />r1s. Ttt Oh1ED <br />Sa C <br />TtON. CBE A- i.teh. DA <br />)) <br />f1 <br />a° <br />i <br />DA RSo <br />Issued June 14, 1957 <br />'n <br />