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social Security No....._._.._ ...... ...... ....... . ..... State FIT* No— <br />I OF DEATH t 'SUAL @C �.OF DIIOZAMW,. <br />(a) county....- . 11 " <br />- - ---------- . .... . . .... T <br />(b) City or to. (a) 6 (b) 0 tr <br />c ty or <br />Npwoot boaD imu R RA c) city or town <br />(I out. <br />c <br />(d) S"pd <br />(d) L-Eth of stay. In bovital or <br />-i6%4 "o. <br />In this counnualt, . . .......... (a) I, our in U. S. A. t.-. <br />R�_ . . .. . ....... <br />days) MEDI CERTIFICATION <br />20. Data of death: Man 1_7 <br />8(a) FULL NAM a2x�. ........... ......... minute ar, <br />3(b) If veteran. -by rtff, that I <br />usave_war .................. .... . ....... . ............... . ......... . .... . ........... ­ -- -- - ------- #..._ I I <br />L Color or S(A) Slugla widowed. mwAed, that I last — h,*em..U_ it <br />and that death occurred daft I to <br />Sale. Ofoiatd 4; 41(e) Age of <br />a <br />,�j -He If alive—y". <br />7. Dirth data of d....&.. Due <br />L AGE: Two I mentim, If lm them coat day <br />Due to <br />-br. ad., <br />Other emadiflona-_ <br />(Indade Praunamer within 8 months 99 do*) PUTWOUN <br />10. Usual arm br finding!: <br />11. Ind.." of <br />I lbib death, <br />I8 Sirthpbn_ L a <br />ty. foreign - - reentry) Of an <br />K&i&u <br />Birtbp 22. If death wore due to external ammem, fill In the foUwwbxs <br />b <br />(City. (a) Accident. ealrdo, or hund" Opodfy)_ <br />IL (a) If—t' <br />(b) Date of <br />(a) When did Wray occurL. <br />17. a) Tcil� at town) <br />it (Ductal. oya v. <br />rma vat) 1) (d) Ud Injury omm In or about boom an farm in thm"", <br />(a) PI ; Unrial' or T!YNY . pypt <br />IL (a) Signato, ai (Speaft <br />woo at oggow <br />(b) <br />2L fisaa <br />Issued May 7, 1959 <br />