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F' SION OF VITA- STATISTICS
w^RTJFICATE OF DEATH
utc 7"
*'<
So.
I. PLACE OF DEATH .. COUNTY HAMILTON
*. cur. village, o* location
. LENGTH 01 STAY IN U
2. 'USUAL RESIDENCE
q. STATE
OHIO
(Wh<i< uiciikJ
ii lAXitwi.on: At''
dencc befoic *di<M__ __ ...
*. county HAMILTON
. CUT, VILLAGE. o< LOCATION
Cincinnati
a(l) a*1 " itipital at laililaliaa, |>/ ilttit miittu)
.HOimirituMt.oN<01 Good Samaritan
a hace or death inside city limits?
Woodlawn
d. ST8EET ADOMSS
'10109 Wayne Avo,
.. IS lESlOENCE INSIDE CITY LIMITS?
I. IS SESlOtNCE On A /AIM?
rn fy no D______________
3. NAME OF DECEASED (irrt Oi fsiNi)
fmi Henry
Nt-
Middle Hoerst
YTsXl NO
Utt
4. Date DEoArTH
YES n NO rX
Month
Cut
Y*r
Oct. 17, 19^3
i. SEX
4. COLOl 08 8ACE
MW
ID*. USUAL OCCUrATlON (Cut iimi #/ war* iamt
4vti*t <> !
lilt, arm 11 tatitai)
Beaterman
7. MAid ED IQ NCVE8 MAItlCD C
WIDOWED O
0IVO8CED
I0S. KIND Or SUSINESS 08 IN0UJT8Y
Asbestas Mill
t. DATE or SI8TH *. ACE (la ftari 11 ilalaf 1 Tir II War 2\ Hit.
10-1U-99
iai^itfliimj) Al.xdij Daft Ilam>i | Mia.
II. SISTHriACE (Slait at jattum taamtti)
OliiO
12. CITilEN Or WJLAT .iOuNUY? U . S .A
IS. TATHEB'S NAME
14. MOTKEE'S MAIDEN NAME
Joseph Hoerst
Catherine Stando:
IS. WAS DECEASED EYE! IN U. S. AIMED TOBCES? (Yf/.^^at aaJaaiam)} {!{ }ft, lirf war at Jam a) lftrift)
U. SOCIAL SECW81TY NO.
270-07-0i|.0$
ir. INFORMANT'S NAW^q Wfl Ida Hoerst tfooclawn
' <V*iit. CAUSE OF DEATH (frrr aamltjj M>l <<am* ptt hmt lir <4), (S), ami (<).)
fAIT I. DEATH WAS CAUSED Yi IMMEDIATE CAUSE <>.
MLtWdLJ
oA,dAdivrue. io
INIcSVAL SETWEEN Onset and death
if **i'\ t>\)i TO 'fc. wink tart tilt t* I
miatt taait (4), > ttahat tit aaJft. ) tj,nt Iftll Jajl.JOUt TO (at.
7--3-^-0
3 oyjiAA
: tat. liiaificut C.a.iii* (mmiM i tula t mar liuil^i* Hainan eimii caaamaa < ia r*ai |I*J
q
. was AUSOrSY
YES Z><0 D
20.. ACCIDENT
SUICIDE
HOMldoE I
70S. OESClItE HOW INAI8Y OCCU88ED. (mltf malart / im/atj im Part i at Part ii #/ ttam it.)
~TU*u> Lu-tLsQ_____ GjuJ si*!.
) 20c. TIME Or iiaat 1NJUIY 4. m,
Dai, Ytmr
p, m.
IN/UtY OCCU8BEO
SLWHILE AT
WOIK
NOT WHILE
21. / atuaiti tit itttaiti jrtm
20*. MACE or IMJU8Y f. tm at aiaafl*m,
l*Oit?a
0$t0 hidIt, tj<a)
201. CITY, VILLAGE, O* LOCATION
COUNTY,
$:.. /<3/_/? i%
ami tail taw
a/ii t a*^J-C*/-J-3
STATE
Dtati atlarttJ aJ . -______ I i
m am lit Jale ttatti im 4; ami ta lit itil a/ mj imavhif, Iram lit taaiti Haiti.
.Signature*
Jb. A0D8ESS333 3 O
^UiT
JJ<. DATE SIGNED
I
}2*. LUtlAL, OEMA. TlON. (S/Yfi/y)
Burial
23b. Date 10-21-63
J 23c. NAME Or CEMEU8Y 08 WmaTOBY 1 St * Rotor cc Paul
33d. LOCATION ' (City. town, or County) Reading Ohio
(Sun)
34. NAME or EMLALMtt Gene Henry
(Lie. MO.) 70S A
H. flJNiflAl OUECTOB'S S'CNATUBE ,yCCa6u/ -s/t .
(LlC. NO.) $3$0
2*. rUNECAl ri8M AND ADD8ESS aSchmidt-Dhonau Co*
(STACEY NO.)
/
k33 Headinc Rd.
IOTY) Reading ISt.
(STATE) Ohio.
27. DATE IECO Y
HJ. 8EOIST8A8*S SIGNATU8I
iof \
'--'
U 39. DATE 8ECD 6Y SU8.8EGIST8A2
r. /A
3D. $US*BEGIST8AB`S SICNAIU8E ----------
--
/
I hereby certify this, to be a true and correct photographic copy of the certificate on file with the Cincinnati Board of Health*
nfEi - 17 1 ' DEC 5 1963.
Local Registrar -
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