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4/16/2012 1:52:22 PM
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Z <br />VIE <br />PH,--,1&VS- REV 4-57 0 <br />STATE OF NEE ASKA <br />DEPARTMENT OF P�BLIC HEALTH. <br />EDUCATIOX AND WELFARE DEPARTMENT OFRBEALTH <br />'OR'- CT[-r) HY AFFJCAI,,jTCERTIFICATE Bureau fNI'tal <br />tt-, T I <br />BIRTH NO 126 .11-27-1C;59 ' O'FD <br />STATE FILE NO <br />I ENLACE .1 -.1. <br />A co"ll <br />77�� <br />STATE b ccu.i, <br />• 1.11 T... E. -- <br />LENGTH OF STAY IN lh <br />" eL I' <br />CITI. TOWN. OR -7*1 <br />.... rr .... --- <br />I ITIOT I <br />LE, Ltz�te Ltl eLt <br />T I 14IT5? yESo ROM 1. IS AlllC- iNSOE 11TI 111 4 If FA-RESIDENCEI <br />11TI <br />A. NO <br />3 <br />A'l A DATE M-" <br />t-AR. Ed, A DATE M-h D., y- <br />v—, -v 01 pct.. lir <br />A <br />6 COLOR OR RICE 7 MARRIED NEIE-ARRILIDE] 8 DATE OF 71 9 AG 11, N UNDID. Wh 1, 5N - i-.N <br />-ER A ARRI <br />ED Idt DZT.11 ENAAN <br />e L ALOO-D ❑ D-NCE. 5 <br />AL7 I �. C <br />L F <br />IW IS LMCIFITA) UOS FIND-IlIkESSORIADILITEtY 11 T-ACljVWl.lflly) 12 CLIDNER OF-1 -11 <br />S_SS I A <br />R I STAY <br />L H C- <br />tj -till II/l. 1- If <br />I.c f! &6"b <br />--THER <br />J-b S -DIN NAlf fk4fOLHUSBAND OR MFE <br />1'0" <br />porict vc,,rL. <br />A-El FORCES' 16 <br />SOCIAL SECURITY ;0--1 <br />AIAM- <br />17 IKI&R Aeerrer <br />Delilah <br />io <br />. .1 --r. iF.- ... .., C.- " h <br />18 c.. 1.). 01. -d <br />D'ETOFEE.- <br />I: AT I CN.-AS CAUSED At <br />1. LATE CAUSE <br />M2& <br />C-do-DUE TO ' T". (,) <br />d ,,A, <br />I <br />..A, <br />I <br />o PART 11 O1N(ASA;AUXAllCOADLT-C FLARAUL D-LE OCRANDAN GMEI 11 PART -1(.) 19 <br />-T. �--Y-Gl IALAFED TO <br />Pf AU7OPS <br />K. <br />.FONI <br />YESCI MOE3- <br />K11161 -6, <br />CAD CIE. IIE IOW INJURY OCCURRED (ERIC, Adult ofinjulrin Part IF, Pmt IlefYen 1#) <br />201 1- IF H.- Mh. III— Y- <br />U,jURY <br />Z <br />20d '"JURY ICURREO <br />III ILICI IF (I. f, C, - AD— <br />CITY.;— &A --ATICK COUNTY STATE <br />TRY <br />=ILI A NOT-LE <br />AINI. (AN-. $-t, ml, bid,_ AF <br />120I <br />A. AT RORK <br />ZI d It. And Z -t E., D, <br />D-N O1 CA <br />21. .14 <br />7 <br />DATE 5111E <br />SI, <br />23R V. l,LCRA-RbW,.j �6W. 123t M.EOltEYRH.YC.O-ATORY llld,. <br />LI . <br />,LIAT*" <br />24. DATE 777 OF YORTVARY .... <br />A, <br />
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