|
<br />STATE OF ILLINOIS)
<br />County of Cook)
<br />.
<br />
<br />200704~O'O
<br />
<br />AUGUST 29, 2005
<br />
<br />DAVID ORR, County Clerk
<br />
<br />)avid Orr, County Clerk of the County of Cook, in the State-aforesaid, and Keeper of. the Records and Files of$ai~;Couni}t,d6hfilreby certify that the
<br />~ched is a true and correct copy of the original Record on file, all of which appears from the records and files in m~Qftjse: ~. I. .
<br />.';-"L ;" ",,', ,..:.,.,..,..:,:1 .:'~':':.;';"" ';;., ' '~
<br />WITNESS THEREOF, I have hereunto set my hand and affixed the Seal of the County of Cook, at my officeinth~CltY-ofCh~ In s1~. County.
<br />
<br />......~.D~
<br />
<br />COUNTY 'CLERK-- ,a
<br />_ _,...,. -I,,,.,,,, ,", .~'Y."",' .',.>~.,_ ,~_~.:.-..,.,..;,~_".~ '.,,".." ,,'
<br />.. ~. ,"
<br />\ ~ '::~, :2. ,,-,'
<br />
<br />, Sf ATE Fill;
<br />NUMBeR
<br />
<br />I BIRlll NO.
<br />
<br />16.U
<br />
<br />ST ATE OF ILLINOIS
<br />
<br />REGISTRATION
<br />DISTRICT NO.
<br />
<br />""fltlfl
<br />iNr INK
<br />DI""'Qn,
<br />"Y8lcllItM
<br />_tw
<br />TION$
<br />
<br />REGISTERED
<br />NUMBER
<br />OECEASED-NAME
<br />
<br />MEDICAL CERTIFICATE OF DEATH
<br />
<br />
<br />FIRST
<br />Adeline
<br />
<br />MIODl.E
<br />
<br />l.AST
<br />
<br />OATEOFOEATH (MONTH, DAY. YE;ARI
<br />March 15. 2003
<br />
<br />C.
<br />AGE-lAST
<br />BIRTHDAY (YRS)
<br />
<br />1.
<br />COUNTY OF DEATH
<br />
<br />Cdok
<br />
<br />4.
<br />CITY, TOWN. TWP. OR ROAD DISTRICT NUMBER
<br />
<br />~~A~~~~l~~C:ii~g~
<br />6c. Inpatient
<br />WASOECE;ASEDEVERlNU.S.
<br />ARMED FOIICES1 (YESiNQ)
<br />9. NO
<br />
<br />
<br />6a. Oak Lawn
<br />BIRTHPl.ACE (CITY AND STATE OR
<br />FOIIElGN COVfmIY)
<br />_ 7.YOUNGSmlrlN OHIO
<br />SOCIAL SECURITY NUMBER
<br />
<br />8b, LAWRENCE J.
<br />KIND OF BUSINESS OR INDUSTRY
<br />
<br />6b,
<br />MARRIED, NEVER MARRIED,
<br />WIDOWED. DIVORCED (SPECIFY)
<br />8a. HARRIED
<br />USUALOCCUPATlON
<br />
<br />NAME OF SURVIVING SPOUSE (MAIDEN NAME. IF WIFE)
<br />
<br />
<br />11a.HOHEKAKER
<br />
<br />11b.QWN HOKE
<br />CITY, TOWN, TWP, OR ROAD DISTRICT NO.
<br />
<br />138'. 7801
<br />STATE
<br />
<br />13b.PALOS
<br />RACE (WHITE. BUlCI\, AMERICAN
<br />INOIAN.OlC,)(SP"CIFY)
<br />14a WHITE
<br />l.AST
<br />
<br />HTS.
<br />
<br />
<br />13eILLINOIS
<br />FATHE~ME FIRST
<br />
<br />14b. Ii NO
<br />MOTHER-NAME
<br />
<br />[J YES
<br />FIRST
<br />
<br />SPECIFY;
<br />MIDDLE
<br />
<br />(MAIDEN) LAST
<br />
<br />MANNINO
<br />
<br />15. VINCENZO
<br />INFORMANT'SNAME (TYPEOIIPRINl)
<br />
<br />16. MICHELENA SISTO
<br />RELATIONSHIP MAILING ADDRESS (STREET AND NO. OR R.F.D.. CITY OR TOWN. STATE, ZIP)
<br />
<br />
<br />17a. LARRY LOCASCIO' 17b.BUSBAND UILLA DR. PALOS HTS,IL60463
<br />18. PART I. Enter Ihodi..,sS9s, or complications thaI caused lhe doath. Do "'" enter1he mode of dying, such as cardiac or r8$plratory arrest, """""".....'" ,mEAVAI.
<br />. hShoek' or heart failure. List only l)I1a causo on each line. """""EN""SET^""OEATH
<br />Immediate Cause (FInal . .. ..
<br />disease Of ccndl1Ion (a) S ~ C *'t.p I 0""'\1"'0 P I'1-'TH1 .
<br />rooulIlng In death) { DUF. TO, OR AS A CONSEQUENCE OF .
<br />
<br />CONDITIONS, IF ANY .1 _ ~ .. I _
<br />.WHICH GIVE RISE TO (b) ~\ 1-........... .
<br />IMMEOIA TE CAUSE (a) . DUETO, OR AS A CONSEQUENCE OF
<br />STATING THE UNDEAL YING
<br />CAUSE LAST. (C)
<br />PART 11. Q!h<!!;fIll!Jlfj9.!ll ~'!!l!'! _~og to "".'" 1>0< no! """,llIog In tho """ol1ylnv """.. """".. PART I. ......""""""'..."""'..V......... """"'TO
<br />~OFCAVSe:OF~nrr('tt'Si'NOJ
<br />19b.
<br />
<br />DATE OF OPERATION. IF ANY
<br />
<br />
<br />MAJOR FINDINGS OF OPERATION
<br />
<br />20a 2Ob.
<br />I (DID) (~ATTENDTHE DECEASED
<br />AND LAST SAW HlMlHER ALIVE ON
<br />21a.
<br />TO THE BEST OF MY KNOWLEDOE, DEATH OCCURRED
<br />
<br />IF FEMAlE. WAS THEAE A PREGNANCY IN PAST
<br />THREE MONTHS?
<br />2Oc. YES 0 NO
<br />WASCORONEAORMEDICAL HOUR OF DEATH
<br />EXAMINER NOTlAED1 (YElmO)
<br />21b. No 21c. 12: 00 P'M.
<br />E TIME. DATE ANO Pl.ACE AND DUE TO THE CAUSE(S) STATED. DATE SIGNED (MONTIi.DAY. YEAR)
<br />7uOtf1. 22b. >/1 0 ~
<br />ILLINOIS LICENSE NUMBER
<br />
<br />
<br />22d. 01(.-1 ol<{ r.t .
<br />
<br />LOCATION
<br />
<br />NOTE: IF AN IMJURYWAS INVOlve01NTHI$
<br />DfATltTHlI COIlONEROR MEDICAL EXAMINER
<br />'NoT.1I NOTIl'1l1O.
<br />DATE (MONTH, DAY, YEAR)
<br />
<br />CITY OR TOWN
<br />
<br />STATE
<br />
<br />24c. JUSnCE, IL.
<br />STREET AND NUIA8ER OR R.F.D CITY OIl TOWN
<br />
<br />24d.HAR..18" 2003
<br />
<br />STATE
<br />
<br />ZIP
<br />
<br />9900 W. 143RO ST. ORLAND PK, IL. 60462
<br />FUNERAl OIRECTOR'S IlUNOlS lICENsE NUMBER
<br />
<br />llUnoIs Depal1menl 01 PubItc Hea~ of VItal Reoonls
<br />
<br />
<br />~
<br />
<br />
<br />
|