Laserfiche WebLink
State _ (b) County <br />x it utel city r Yi write R (e) City or town _ <br />ga (c of hnD) ( tution: (if ouu Ida )city oor te Ilmlh, write HORAL) <br />a(If net (n oeD tai or Institution per to street lam on) (d) Street No <br />Length <br />(d) Lgth of etav: In ho7yltal or Institution__ J/J rued ehs lonaLion) <br />In tbls eommudt7 — y�.J /• nlfy Wb¢ther �% "�'� (If <br />years, months or day_e) — ' - -- Ie) If loreign <br />1. how lour In U. S. A.t <br />` <br />MEDICAL ypi CERTSFTCATION <br />8(a) FULL NAME �(�I f � 20. Data of death: Mouth_._O— d44 � MyJ <br />SW if vataraa ,43L— hour. -i2_ 'hate <br />21 -I hereby certify that I attended thy /ij/ Lr <br />Color or 6(a) le. Idowed� man 18 to <br />w <br />that t lest saw hdCyall» <br />diyorc _____ -_.._ <br />of husband or ge and that death ae mead on the date gad hour stated above. Duradsn <br />A <br />Lamadiate cause death �7—� <br />wife If 11 _ �fi ����+�✓,qp,j.. —�, ��[_ <br />7. Birth date of deceued— <br />(Man <br />B. AGE: Yeuf I o the Days If Ins than one day <br />D us to <br />6 _mla Doe to <br />B. HlrthDlea -- Other — itiom — —_ <br />(City. town, or lonely) (Scats or o»IYn country) (Include pregnancy within 2 months of death) PErmCIAN <br />b 0. Usual — nation Lr{.�syrr r- B- {---- - - - - -- — - -- _ - -- - -- <br />9 Industry oe ml r� "'"�—� - -�— Maior endings: U.derB— <br />6 s (12. xame .4 ' Of operations = - - - - -- - - -- the a » <br />ti <br />J)l 19. Mo. �/epgip -- -- ^ - -- _-- _- - - - - -' should b • <br />ye a lC . To unty, 19LE'xl fo ei <br />I f° �p /��L�1? <br />Of antnDry ----- -- - - - - -_ ehargea Ha- <br />ts. Malden n.me }� , thrticalb. <br />Q q 16. SirthDla» 1- - - -- <br />g( ( . town, or county) (S or fo an entry) 22. If death was due to ezlsrnal came, All in the followinir. <br />is (.) Informant's dgnata »� (a) Accident. suicide, or homicide <br />(b) A dews _ (b) Date of ocrnr»ne <br />w 17 (a) ` (b) Date thereo _ (c) Where did Injury olcmt -- — ------ -- <br />(Bari.. _.atiou, m removal) ( t) )� (City or town) (County) (State) <br />(c) Place: burial or cremati (d) Did Injury occur 1n or about home, on farm, In industrial place. b <br />Dub11l Visual — (Speally type of plane) <br />18 (a) Address of I¢ _ — - <br />(b) Ad�fdtr(fe�tssT ._CC— _ Whlls at rl __ (a) Mean• of lafary <br />1➢ a) _L.1Ll_t2_ (b) 28. Signaka �'.�g (IL D. or 64kW)— <br />• (Date »nlyad local reaistrar) f?zftwtsa' Hgoatute) I Address. 's - -- Deft !NM!f6!nj:gW ; <br />Issued July 6, 1959 <br />MA <br />