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( <br />i <br />v <br />9 <br />�a <br />a <br />1'f Rl.11: HEALTH SERVICE .•` . >` >,> 1. a r ova <br />BtIreau of Vital StatLvtic3 <br />l:urrn NO. 126_______ CERTIFICATE OF DEATH <br />- - -- - -_ STATE FILE NU <br />1 l'1 ACE OF DEATH - -- T- - -- -- USUAI. RESIDENL'E (Wh Jec J head. I( W(ADon <br />COON CY / t { STATE }� 1.. b COUNTY '; iJcam <br />b CITY (If oy W6 p„rnle Um to n <br />Lhte Qa d) 1" E N C T 11 OF c. CITY II' roryornW bmt write URAI.I `- _ - -- <br />I (It / STAY (m the place) OR <br />TOWN <br />I. FULL 1 NAME OF (1f t t ,tat ur ,n t W Ftoi t .tad a .^ J. STRRET (I( d, gi IoraUOU) s� - - - -- <br />11 OR <br />location) AllllRE$S <br />11 <br />1Nti1111ION <br />] N. A Ok t <br />D_F(F ( ktr e <br />) � (M -dJle ) {. DATE (MyOlh) (UaY) (Ye AS m) <br />_ DEATH. ,, � _S <br />COLOR - _ILACEI <br />T. MAILl111.D, NEVER MARRIED <br />8 �.j)ATE OF BIRTfi <br />9. Ago (In ­a.1 <br />if ndcr 1 Yr. I4 Undcr 24 Hre. <br />I6. <br />WIDOWED, DIVORCED {Spe$ty) <br />/ <br />Wt birthday) <br />UeYS Hour Mln. <br />�c <br />1 ^a• USI AI, j>,l:l^j,l Af}ON (G k pd d - k' 106. KIND OF "I;SINI ti`S t1. )ilk E (City, to u ty) (State)l2. /CITIZEN OF WHAT <br />1 Jo�v J 'pDll�f iP'Ic)pyt li4p v 1[ ti:/'cti J)I AR INUUST Y YLAUE I - COUNTRY <br />f .�q cmrntry) I <br />I - <br />�:tLLFA1HER'S NAMR Dl MOTH 'S MAIDEN NAME v <br />V. I � � 1 {b NAME, OF HUSBAND OR WIFE <br />i <br />_j <br />15. WAS D} t EASk D EVER . M ST <br />IRJ t o (Y 0-Ti[ y4', t Rrte) <br />16. SOCLAL SECURITY IT, I RMAT'S NAME Sigbet &Add e <br />, <br />NO .I <br />IN lA SF U! 1EATH <br />Entek I ooe r <br />atnd <br />D1F:DIC'Af (;Ef1TIF1C)ATIC)N <br />Intent) Ellt.ihd� <br />line f _ ( ), (b), (c) <br />1. DISEASE OR CONDITION <br />DIRECTLY LEADING TO DEATHe l /�,7 (/ �� <br />- ...... <br />0nxt d Death <br />•Thia dole not mean the <br />ANTECEDENT CAUSES <br />' mode of dying, each u <br />... .. ... <br />DUE TO (b). .._. _........_. ..... <br />._......_.. _ .... .. <br />heart (stiure, tethenit. <br />Morbid eonditione, if tnY. [Trio[ <br />ere: it to.... the dia- <br />inlvey, <br />rile to the tbore crux (t) etttin[ <br />cue, or romplath. <br />Oon rrMeh ouxd dnth. <br />the vnderirin[ crux tut. DUE TO ' <br />(c) _... .........: <br />.._.._..... _.......... <br />_ -_ -_ <br />IL �YTHER SIGNIFICANT ('ONDITI <br />C nditioo o trlhutinx to the desth but t <br />b,t <br />refitted to the dixcare o nndition c xndetth. <br />rOF <br />I vt. DATE OF OPERA -I <br />191, MA1011 FINDINGS OPERATION <br />TION <br />20. AUTOPSYP <br />Yes 0 N.X <br />211. A( CID (Sce ify) <br />SUICIIJE - Ihome, <br />216. 1'WCE OF INJURY (r. x., i r about <br />[arm, factory, <br />21e. (CITY OR TO (COUNTY) (STATE) <br />HOMICIDE <br />ut"t, office bldg., etc) <br />(If rural area, write RURAL) <br />