Laserfiche WebLink
VT4,TF (W %WItKA4WA <br />A .011'691.1111T OF P13111.1"" HEALTH. ]DImPAXTxW%'T'fW n -el tai.. t r' <br />icibuv&Tsm AND WELFARE BISTmul of vital'Statintlics <br />IDDS55 <br />Cf.WTMC_4,TE i(W IVEAVH S1 11%T1.11 FILE NO. <br />BIRTH NO. 126_= - - — � , __ - . I - I I- - ­­_­­__� <br />- �a; � If uscAL'nfiwlw�_ W <br />!�CPLACE'av D"'Ti STATE " t' b. COUNT Y 4"l—a. be— A.Who, i <br />HiUl <br />COUNTY .: <br />,.rl._. linni", ­JwRarall �STLE N G T:ff OF CITY (if ut.,jnj� —1-1- li-i". —itr RURAW <br />Ott <br />X <br />OR TOWN <br />TON <br />(j'rurml' Ri- location) <br />nm in boolm, or <br />d, FULI, NAME OF 0 ADDRESS <br />HOSPITAL OR <br />N.;TITU-qON <br />__JA;� — LA. J)ATE (lifunth) �(Jlsy) (Z�) <br />ib. fMiddle) <br />2 7 37.N—A 4� 01- (Fmt) <br />DECEASED <br />(IF <br />t�l -H era I <br />Urolurl <br />'.1 if <br />;4, COLOR - RACW" MARRIED DATE OF BIRTH At (Io yr, <br />NEVER �MARRIED <br />WIDOW'Em.- DIVORCED iSW6 Y "'t Min' <br />XN OF Whi6 <br />.2 W it. BIRTH fC[tY, to"n or —uty) flltaw�12. CIT17 <br />OF III 'OUN"PRY� <br />M i,,- kind of — <br />I". USUAL OCCUPATION 1( i'Zk'jGb. KIND CR N�ll L tX �PLICI�_a . or for Tr 1,amtry) bs� <br />1), 1 , np4li, ". <br />urf ­a "Z r ibc Foods GO or <br />do 'MV - "'ark E <br />In . asion I <br />1 Iu. MOTHER'S MAIDEN NAME l4h. NA F HUSBAND Olt FE <br />'lr�1" �3FXTKER% NAME I <br />m I Susie 1"�hffts <br />-IAL SECURITY r. 1N-FORMANT!S.NAUE -r Sicnaturr & Addr- <br />rVER IN U. S. ARMED FORCES- 16. SOL <br />i" 16. N%'AS I U. or d... of "-�,Susje Lei-mg, G_nicmd 161RMd <br />a Z' <br />',%jEj)j(,.VL ('ERTWICATION D—t _W -D—m <br />r1,17SE OF 'EAT" <br />only F",.I. DISF.,,,, '0 :,'tl an <br />Entul ��E DR ( NDITln%l <br />I- for UlRE(.TLY LEADING TO DEATH' <br />-Tbi. d— natmean the ANTEC.ET)E%, CA•SES DUE TO (h)_ <br />k of dyi.19. <br />.."h-.. mo 4.1 'Wing <br />d ;t' """ <br />" K". ..derlyinic mu" I"l. DUE TO 16. <br />tim which —used Bath . <br />n. OTHER SICNII.ICANT (;O,%I)]TlOI:S <br />Condition, mntributing In the dexth 'but mGtLh. <br />reiated to kv di— or —dition --M-K - <br />AUTOPSY <br />t�i, MAJOR FINDINGS OF OPERATION <br />OF -Y- —I- N..:. <br />hno, 21, l(TTY )WN) COUNTY) <br />'NT ­ify� 21b. P,!-ACE OF INJUR.'_ If ­ju. RURAL) <br />z ACCIDR (s] f_, bldg, -t,) <br />SUICITIE ----- -- <br />III (1c CTIEREIF _lf. HOW DID INJrI"Y Occ'UR: <br />E 21d. TIME Month) (Day) (Y—r) tAour whil. at Work ❑ <br />' INJVRy <br />OF to. No, Whil. 1 K :1 <br />that <br />I Iasi saw �thc <br />I hereby certify that I attended thr deceased trom the date xtated ob- - <br />and that death OCCUrreti at... ftam the call.jes a vid 01 <br />ceased alive On ....... ... ... 19- - I _ - --- - or titW) 23b. -'I, 11ATE SIG' <br />0mg- <br />23.. SIGNATURE <br />tR in! c <br />Tjv !.,-n 6F­Fj�N_jE,�kj�Y_Olt CREMATORY 24e. LilCAT ION -Vv. �'-­ -_17-ooty DE NAb1E 2.. <br />24.. BURIAL X] I <br />CREMATION m r Park 'em"Ze-V sl Aim. <br />la'Sme <br />DATE REF -l' Bf'LOCAL <br />REG <br />F. S. <br />z y)l - — -�o <br />RECISTpAR-S SIGNATURE <br />Li <br />i <br />