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H <br />Qi <br />DEPARTMENT OF 1[]F-1kLTH <br />Division of Vital Statifidw <br />STANDARD CERTIFICATE OF DEATH 9484 <br />DEPARTM OF COMMERCE <br />BUREAU OF THE CENSUS SWIM S-Ity No........_.._ ... stntl Fill NO.. --------- --- -- -- - - -- <br />1. PLACE OF DEATH: USUAL ?jf7IDENLCF �OF DECEASED: <br />W Goonty <br />(b) CitY or t- - to (t) City or <br />(if o-id, r t or of or W RU L) <br />wltrrt N <br />If kn.1�616 :�a <br />I no I. J o) <br />tit of stay: In h. ZW - i - Zo <br />tit. I. miso ,o_ hrw long in U. S. A. 1 ........... . ...... <br />. ..................... AL CERTIFICATION <br />In this w... .... or d-) <br />01�0 .... .. .. ....... <br />V.) FULL 1 21. 1 h1mbir m Y that I sty <br />3(b) It vetaray. ..... .. ...... .............. . ... ......... ........ <br />.........\. ......_.__..._._.._......__.... <br />I. color Slost. widowed. nnd tht d,,th rolword on the dati, and hour -tlt-d -I--- <br />dI, loon"I'll cease of -- -------- - <br />kulb-, or Aill of .. . .......... . ...... <br />... . ............... . i? <br />- ---------- - <br />- <br />Birth d- t deceased... ..... - - ----- <br />(Month y <br />1.8 AGE- Y- I Mon D-_] R Ieaa thaw dar <br />Other -ditt- <br />. . ............ <br />W <br />. ;& of W* pffmcuN .......... . . ..... . ......... .... . ........... <br />0 <br />Of.1-tI . . . ................... -, ...... . ................................... ::,� <br />.... . ............................. ...... . ........... . ...... ........... - ............. -... ...... sb..Id be <br />ob--d <br />Ofavtoac l ............._............__._........_..... ........._._..........._....... tWirtlyaW <br />22. If depth ­ Joe to axWr..a -, fill in the fu.'ringt <br />(&) Accident, midde, or bmddde . ............ .... <br />(b) Data <br />(.) Wh- did W- <br />(,I) Did inju, bout horns, ifulustrist Vl� in <br />publis .1.-? .............. <br />low <br />2L -of <br />3sued March 10, 1959 <br />f)17 <br />11 10 ­1 <br />Ul <br />11. d-,�, or i, i <br />1, 1, on <br />13. BltthlL�� <br />w (City, town. or <br />33 <br />J, <br />........... <br />(city, w- or <br />I8. (1) Informant's <br />(b) <br />17. W <br />Pl.,,; b,lsi or -ul <br />81 *1 f I&I d1o" <br />(b) <br />Hi. (-) <br />Other -ditt- <br />. . ............ <br />W <br />. ;& of W* pffmcuN .......... . . ..... . ......... .... . ........... <br />0 <br />Of.1-tI . . . ................... -, ...... . ................................... ::,� <br />.... . ............................. ...... . ........... . ...... ........... - ............. -... ...... sb..Id be <br />ob--d <br />Ofavtoac l ............._............__._........_..... ........._._..........._....... tWirtlyaW <br />22. If depth ­ Joe to axWr..a -, fill in the fu.'ringt <br />(&) Accident, midde, or bmddde . ............ .... <br />(b) Data <br />(.) Wh- did W- <br />(,I) Did inju, bout horns, ifulustrist Vl� in <br />publis .1.-? .............. <br />low <br />2L -of <br />3sued March 10, 1959 <br />f)17 <br />