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STATE OF MICHIGAN
DEPARTMENT OF PUUUC HEALTH
CERTIFICATE OF DEATH
STATE tile NUM3SH
-36b
SciaLOtHI NAME
rttif
SEX
turf OF OCaTh (Mo, Oaf. Y/J
WALTER
W.
HERBERT
* Male
1 August 7, 1978
lUCf 'p| . WMi. A*?*.
*GE -Ue MM#r
**-**. +*. t (Specify/
. White
OViJ 5a ?7
LOCAIION Of DEATH
fCh*fkunn
WMX on UMTS &;
end ipeC'fyt
fj
UNDER 1 YEAR
UNDER ! PAY
Ot 1 O**S 1
* l MMB.
Allen Park
o*rr of bath ir*>. o.#
*. June 14, 1901 jHOSfUAl 0=1 OfTltR
COUNTY o* Of ATH
7. Kayne
7*. SfAtf
0fiffJ*2i
dllXEN 0# WHAT COONTHY
<--C
wUMLMOMOlWKMa.bMOCtVvOMAl CMIMt<i*DK.*r*
.Michigan
f. U* S- A*
to Widowed
SUJRVjtIVAINGllSePOnUSEP(aifwrkfe.Cgioftnmvaratenlenstmctfet ni[uts
Hone
fOVil*
T --
| .YOT"-4*
SOCIAL SfOJRlFY NUMBER
n 3?2-01-15i3
CUHAEHT ACSOCMCE-STATE COUNTY
USUAL OCCUf'AHOAJ fftVe Mrf <?/ mwA *wr dvf*/>g noit 0/
working */,
itfdHrd)
KING OF AuSlVSS or tNOUSTRV
111 Electrician
iib Automotive
o"`*'io. Dearborn Heights STREET ANO NUMBER
*+d 1JWC%[ ] WSMX VAUtrCf UMill <*
\tt ' Hlchlytan is*. Wayne
--/FATHER'NAME Fiats-T
MMM
1^1# William
itt. *Jk*t
MOTHER -MAiOZ* N4M *5f
Herbert
Ida
is, 3918 Academy lyhOCHLE Utl
Korneffel
WfORMANT
Mailing ADDRESS
th a*
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on a to*'!
jtati
*
184. fSkgnaiuftt
immediate cause PART I
M
OUE TO, OR AS A CONSE'
m iioirn'out TO. OR AS A <
fart U OTHER significant CONOITIONS-
b 9438 Hortenview
ONLY CftfCAl/Sf P* LWEfOA faf. ff>i MO ft#/
fr/l-lr/ $
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Thylor______ MI <>5180
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AUTOPSY fSpecify Ywt Y/A$ CAS* REFERRED TO MEDICAL
or Aft*/
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PLACE OF DEATH 'ho^v. 1| >* AeMMCil {Specify!
Nm.
Y HOSP OR BRST, tmtKeM OOA.
OP,r(,P* mm. * fSpecify) ,2V InREC^ient
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OATE SiCNEO fiWo. 0^/jr.i
J HOiN^OF DEATH
2jb August ^/1978
23c
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NAME OF AnewarNG PHYSICIAN If OTHER THAN CCRTtfitft /Type Of PfmtJ
OATE S;G.V=!>
?4T. F>7
aS M< ?*% * " PRUf-OLINC'O Da3 /Ma.. OAr. Yr./
HOUR OF DEATH
2k PAOr.OUKCEO 0!>0 f/4ovr/
M
T24. E ANO ADOBtSS Of CimiflSH imtuCHN OA UIK. Iwm f/yp* erPr*><>
244 ON
2k AT
M
George J. Schmidt, M. D.7106 Park Avenue
Allen Fhrk, MI
StMCAC. *eCP4., KAtUPAl. r 0ATE Of INJURY Q* MHQMG MVttr
fay. Yt:J HOUR Of INJURY DESCRIBE NOW IVJuRY OCCURAEO
40101
Ha
29k.
l<-
264.
WJURY At WORK /3p*c/W Jk Nti w
PLACE OF MANLY-a* *--m. lemm, *". *sa~* -*t
_____ HE
Httn e*t (Sptc4yj
LOCATION , 28
/URIAL, CREMATION. REMOVAL OTHER (SpecfyJ
CEMETERY OR CREMATORY-NAME
I 2?4 Burial
27b Forest Lawn Cemetery
srfcjfT M( WL
nr, wuaCL CW
(TATt
[LOCATION
Of*. VtlAGC CA IbvkNtMiA
STATE
!*
Detroit
Hlchljtan
Date /**>., Oj*. *w
NAME OF FACULTY
ADDRESS OF FACILITY
/to August 10, 1978
FUNERAL SERVICE LICENSEE
(Siffn
Tsfluerfeld Funeral Home,T nc. mJ.200 Oakuood,Dearborn.MI 46124
REGISTRAR
Date received bt Ac5Tar //.Sp.
hi
(V ^
^
I, Bernice Weiss, City Clerk of the City of Allen Park in said county and state, do hereby certify that the above is a true copy of tiia record on file in the City Clerk's office attested by the raised seal of the City of Allen Park.
Lg/Lt^^c-d-fL- c-Bernice Weiss City Clerk
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DTKR 0000223
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Order by Ford Motor Company
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CLAIMS THAT THIS AISEffU WAS DUE
EMPLOYMENT OFFICE
IAS UHAHLE TO SUBKrr SATUFACTOKV EVIDENCE Of tWIUn m OK (CAUS OF HAASES 0* OIXER" 1AELE NEASOHS OUfftNC TOE AEOVE PENIQO. TW^S MW EE CyctUftfTO AS-All ImNUTMONn'FEI .NNFHFF
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INDUST*LAI. RELATIONS
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la HERBERT,
WALTER
fdto MWOttOMMHY
lAOOC NO.
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R 7194
I DEFT. NO.
LOCATION-ACTIVITY
3/22/61
14530 S. TELEGRAPH
BLAST FURNACE
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TAILOR, MICHIGAN
PHONE NO. LU 28861
OC. SEC. NO.
712 01 12U
EXPLAIN SPECIFIC REASON FOM LEAVE
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EMPLOYE'S CO. fENKHUTY DATE EECINNINM DATE
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OFFICE WLf
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DATE ISSUED
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