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f <br />i4 <br />i <br />p4 <br />F�y$yyy <br />my <br />;� ga <br />iR <br />%Q <br />t <br />PRS RAZLYs) REV. 41 STATE OF N1�RANRA <br />AGENCY DEPA$TAIENT Qi' HEALTH r% `.�r�t� 3 3 N <br />PUBLIC � <br />HEALTH S ti <br />PUBLIC HEALTH SERVICE HUdlall of Vi tattetica <br />BIRTH NO. 126..._.. CERTIFICATE OF DEATH SLATE FILE—( <br />!. PLACE OF DRA/TH %, T_l e i, .. S. <br />USUAL R681DENCR (Whrre deeeaed Iived It in.titWmt ra os <br />y e. COUNTY 14.2 ( (, _ .. <br />STATE I% _ (� L, 0. COUNTY 912le ow .deiwlom). <br />L <br />/ovt.id. <br />r- <br />0. CITY (I! outalw eorponW IImIW; wrfW 1111111 LENGTH, OF e. <br />CITY II( coryor.W HmltA Wrl4 RURAL) <br />SPAY (tq DWv) <br />OR y <br />TUWN ( COr... 6� - TOWN <br />OR ) <br />, 2(' <br />d. FULL NAME OF (if n iv hoeoital er Ivatitutiov, give Street add—, d. <br />STRRET (H �r 1, dw Wutlovl^ <br />i <br />d HOSPITAL OR {{ or loctlo.) <br />7: INSTITUTION I',.L/ .- /u^ ' <br />ADDRESS K %k 1 ��- <br />■ S. NAME OF (Pint) b. (Midd�e) lL..t) <br />�. DATE N}) (DyI) (Y—) <br />8 DECEASED I 1 <br />(T>w .r PMt) fii� .� �: 1w L� t� l� I L� P t / <br />( DR' I <br />S. EY <br />BCK <br />T. BDRREllitEV ER <br />, 18D <br />e. DATE OF BRT f.w ( U Unbr I Yr. <br />H <br />Days <br />H Ud.r Y Ba <br />lltg. <br />W OWED DVORM Fl <br />IM <br />lo.. USUAL OCCUPATION (Giw kind of k <br />done <br />ftz even 1t reHred)I <br />lob. KIND OF BUSINESS <br />O8 INDUSTRY <br />11. BIRTH- (City. Wwn b) lebW <br />I f1.AC t <br />11. LT17ERN OF WHAT <br />UNTfft <br />wing moat of work1nt <br />` 99{{ Cdey�?�nt�) <br />12. FATHER'S NAVE <br />1t.. BOTHER'S MAIDEN NAME <br />IO.;I— HUBBANp OR WIFi <br />lo. WA EGEABF.D LIFER IN U. . ARMED PORC <br />if w.r or detea of wr )I <br />14. SOCIAL, Y IT. INFO N v ElioMw �i A�(br <br />NO. <br />(Yee• no. unlmdnr.) >w. It" <br />C � , <br />17s. cevBE OF DEATH <br />MEDICAL CERTIFICATION <br />Igfv>.1 BNwr <br />Evbr ovl> one ww qr <br />Ilne !or (.), dbl, .od le) <br />I. DIBEASB OR CONDITION <br />DIRECTLY LEADING TO DEATH• <br />OvM D..tY <br />-Tkb 4w net ewe W <br />ANTECEDENT CAUSES <br />meN at bbg, wd w <br />DUE TO ( b)...._..._._...._ ...............___..........___ <br />keyt (Wm. .Z.: <br />eta It mew W 41.- <br />M-M, teditby. H tty, giving <br />r4. W it..b.r. Sew (.) .Wthag <br />ew. Inten. w Le�Nkr <br />dbv wMeM waMd dwO. <br />tM nWrbieg ww Wt. DUE TO (c)_ ............. ....... ..... <br />.,../..../_. ................ ..........._....._...._....._.. <br />._. <br />�_....__ <br />11. OTHER SIGNIFICANT CONDITIONS <br />O <br />C.dltbw wntrihtbg W W dwtit be nN <br />rel.ted b tN dbew or w.dltlw w..lne dudk. <br />Ifs. OF OPERA <br />lob. MAJOR FINDINGS OF OPERATION <br />gf. AUTOPBYf <br />DA= <br />u �t <br />Yw No <br />21.. ACCIDENT (Spicily) 111. <br />PLACE OF INJURY (e.e.. In <br />.bwl fla (0117 OR TOWN) (COUNTY) (ETA <br />SUICIDE ,, rr home. <br />HOMICIDE N Orr_ 1 <br />(.rm, tnetor>. rlmt, otfip Eldg.. <br />Ste.) (It ravel wq wr{4 BUBAL) <br />114. TIME ( th) lDyl (Yw) (HwPjL;l� „INJURY OCCURRED <br />11t. HOW DID INJURY OCCU81 <br />OP d( ^ Wwk <br />tB..t <br />IIiJUSY Not Whit, et Wvk <br />o <br />C I <br />tt•l hmbv c Y EI)a f gttendfed the deceased 11'eTl...� ................ 18..Y_ to..�J.. ......., JB.WY!'Tat I lost Safe the do- <br />1 t .14— d,,.......L -.. 18...x.. and that teatA �1 ° o.m, /*� t eangee and on the date stated above. <br />d7_j <br />0 <br />i <br />