Document RJQ2w8oK2L3qaaGBRMewQbxNX

H i.iaMUN .11//OH 'IA uUDihO Hey Gist No _ . Primary Rg Dist No VITAL STATISTICS CERTIFICATE OF DFATH iu , Slate File No Registrar s No____ -- / I DECEDENT'S NAME (hill. Mioaiu Ljill 'J DATE Uf DEATH (Month Ody, Y&art IN atom idOM. civt NCI fttFQHt ION L jQaapti Robert.-Succi 4 SiOOUCIAAL SCfcCUHf ITT NUMBER 5b UNDlh ' O AH 291-16-1586 6 WAS OtCLOLMT EVER IN U b ARMED FQHCfeS7 X Tew .1 NO 67 Muiitl.s | 1 fj.i* v HOSPITAL inpatient . L*H Oulpatiem rrael arid imfhbvu 1767 Griggs Rd. 01/10/1989_________________ n UNU H t Day HiriIS | MlOule', u OATl OF QlRTH tuluotti Day fftin 9/8/1921 t y.i PLAUL Of Dt AI m \ Chin k only anal / MiHThP* ACE iCily ana Statu or t oil I(jn Li>ui'i<yi Ashtabula, OH <; l Hi M DOA Nursing Home .AHevdence Ottn. 1 '6pu< ,/yi __________________________________________ *2_____ jl City unLAot or location OF Death to courT / or death Jeiferson Ashtabula IU MAHlTAL STATUS Mamed il MJWVIV/NU SPOUSE lit Witv )>* (. vvi MallitM. Widowtfd Divo/uei. RuRiJv'i uarr<uj t r.i tJt CEDI NT S U'u JAl Ou UHAlitih ((,,i hmd ot worn 12b KlNli or HuSlNl t.S iNOuSTRy J..hf .iwnnij niuL,l ,,l Auiiunj mi In- not uie UjUtuU! married i i.. Hi biDtNCL - STAlt Dorothy Cartner Electrical Maintenance rju ^.uuf-rtr >3* Lll Y IUWD t H . 4. .1 AI ION 1 1,1 Ht L I AND NUMBLM General Tire Ohio Ashtabula Jefferson 1767 Griggs Rd. W* 'NStDfc CITY LIMITS7 ljl ZIP cou m ui NOf no 44047 14 WAS DECEDENT Of riibPANU vHloiN'1 iSprjr.dy NO ui fes II (M'S '.P i 1/ L-.ib-il PueMo Hii .in * i . y Nii r < 5p. <N A HA, t /VI 1. . I, White , iTO'.io BJac* 10 DECEDENTS EDUCATION t <fiiU'i<< u j ,V < oiiUoi, iO 12) 12 7 tAlniHSNAML (Fsl M/dd/t, t,, <1 MilhllKS NAM( MxJOit. KhnOvn S,,in,in.< College / f .4 Of 5*1 John Sued_______ VJ.I iNf- OHMANT'S NAME (Tyi/v'Pnuit Oinneia Bucci______________________ tyb MAH iNU AUUHfcV.. 1'i/u/tl ,iniJ Numin t ,,i Hum/ Row/e Np/MOef City in /own Statu hQ CiaJvi i.Dorothy ShQCj joa MMEtTthHoOoD Oorf Idisposition X Buna! l"] CNttnation . . Removal from State Donation D Oinei tSpvcityi 1767 Griegs Rd., .,Jaffirsflnt.iMa--(M&L 206 PLACE Of DISPOSITION (Nurr't' o> uuiwlu// 0/ 20o uOCATlON - City oi Tuwn Sidle othvt plate/ St. Joseph Canetery Ashtabula, Ohio 20d DATE OF DISPOSITION 1/13/89 21a NAME OF LMWAlMH< Thomas T. Flailing 2lb llCI DM hni.lhl l 7353-A 22.1 h/CNATUHfc OF FUNERAL SERVICE uCLNSfcb OH person acting as sucyy -i . ^ Uk ' >. 44 REGISTRAR'S SIGNATURE 22b LlCENSl NuMbEH \ll! t-M. 2 1 NAMt AND ADDRESS OF FACILITY Fleming Funeral Home 6746 49 W. Jefferson St., Jefferson, OH -REXC1VE& 25 DATE FILED {Month Day, Year/ 26a SIGNATURE OF PERSON ISSUING PLRMil 2bb DISI NO 2/ UAIL PtHMIl ISSUED 2bd CtHflFltR dtivirh o/i// tBRKDFS OOWPEHiATKA l*W) U CERTIFYING PHYSICIAN To 1htf hesl 0* my KuywieOye, death OLCuru-d <1 (Ac tm< tJ.dc <iuj pi.iut' anU Joe 10 the c.iusetb) and mjnnei as Mutt d SSSiw L" CORONER On Ihe UaS'i ul e*dfTiination and/or inveil'yatioi' <n m, up.pion Qtdlh ui.i_iieo .J Hit: i.nte Oate ano pidc. and due to the Ldoiell, ,ina manner d$ Stated 28b fiME OF DEATH 2^c DATE PHONOUNCLD DEAD (Mpril/i Dm -'uju 28d WAS GAbl REFERRED to CORQNIH' _ 9:30 A. M 1/10/89____________ 2tie SIGNATURE ANp TlTl OF CEHHHtH - L^ ^^ _ .. xx r-T' N" 2fJ LIDINbt NUMtltH </y i 2tty DATL SKjNtD .V^n/n Pay, Year/ /- // J 'v7 4-4 NAME AND ADDRESS OF PERSON WHO COMPLETED CAUSE OF DEATH tTttm/Pimti Harlan Waid M. D. 125 S. Chestnut St., Jefferson, Ohio 44047 JO PART |. E/iIhi Ule Mijufit s m t,w<npriwl'0/>i lti.il i.,iiiM'0 ihe ileulh Do rxjl t-nlt'r the iiiu.ii >H Uyim, `lUtli ,i^ c.ndidt uf rubpn.ilKi t .(lie'll fchOCL, of Hedtt lotluie L.yil uH, uht* cause on eaoh line (MMCOtATE CAUSE (Find) Oisemie or condition ieiuitny in oaih) ,A * > t, .* V ) f * 1 ^ sJ ^ DDE TO (OT AS~A CONSEOUtNCE Oft V '/ * ^ '^A A|,pi(j>m.ile inlewdl between Oriir'l and Df.ith C" * `u --74 . Seyue/d>aiiy li$t conditions, il any leading to immediate 1 cau^e Enter UNDERLYING CAUSE (Disease or injury thvii initiated events resulting <n death) LAST DUE TO lOH AS A GONS&GUENCE OF, due to (Oh as a consequence of > istructions her Slot PART It Olbjtr ^ym^irjr Cuntiitmi,* comnbutihy to deatti Lul not lesuilu.y m if.c uhUeftymy Odu!>e <ji*en m Part I 3ta WAS AN AUIOPSV PERFORMED7 j'l WERE AUTOPSY FtNI INGS AVAILABLE PRIOTO COMPLETION OF cause of death7 32 MANNER OF DEATH ^Naiurai Ai Lident Li Pending investigation i ^u.Cide v Homicide 0 Could not be Determined 33o DATE Of INJUHY 33b TiMk Of tMotiifl Day. r*j,ut INJUHY 1 Tes yNu 3Jc INJUHY AT WOHK t -J id DESCHIHE HOW INJURY OCCURRED Yes C No M Yes No At home l.n i Street, Itjtluiy, oHige buiiding, etc t&pcCityi J3t LOCATION (Streuf and NawLci State} Hum/ Hmttu Nvttibof, City or 7o> GENC