Death Certificate - Blair, Edgar A_3/12/1971CE�IFIED COPY OF A DEATH RECORD�
. . FILL IN WI1H 1YPEWRIiER OR LEGIBLE PiINi1NG
STATE OF ILLINOIS SiArE HLE
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(q� PERMANENT �
y-� CFATIRUTE
� CE0.TIFIU E D�STfR C�T NON - BTATE OF ILLIN018
acvErrtunr�w. REGISTERED CORONER'S CERTIFICATE OF DEATH
NUMBER
DECEASED—NAMF nur M�oou �wsi SEX DAl
i�M. orVr' t In
�[YMAN[MT IMIf
S�e �.�cl �a �� ' 2.':i 3. �
�OO"^' °'� RACExmirz. H[rqp. ,vnnucµ ixa,v�, AGE—usi • UN ER i VEAR• UNDER 1 DAY DATE OF BIRTH wwrw, o+r,
F"'O°� °"�"O" Erc rocurn CI0.TNWY (�.)
� MaEDee4 fp � MOS � O�YS ; HOU4f � AUN.
IMTRUCTION$ � 2.TL� 1 _ ._ rA �. . �� ' " �_. . .....
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*owv. iwr. o+.o.n o-snucr
U.S. WAR
RESI�+oI
... .���.� � � �ncer��v��an�� VVM1W � �
- �o ' , ��I� � �j10 Cleveland .
� I8. DEATH WAS CAUSED BY: �[r+req orvtr ONE UUSE Y[4 UNE iM �o�, RL �ND (q�
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PART I.
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CONpITIOM. li ANY
" W11KN CMVE NISE Td
I�EOi�TE UUSE (el
STATING THE UNpfR-
' -"-'- LYING UUSE LATT.
fDl/�T[ G11$[
TO. � ON f E .
Acute Coronary Thrombosis
TO, 00. �5 A CONSE�IIFNCF OR _
T CONDITIONS: canpnan cwranuruw ra our� �ur rror �[u*�o ro uuu rncn irv e..r i ioi
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5---------------- _ �«i�vr,suiuo[, nornicmc, �� DATE OF INIURYI��TN, o�r, vicea� �{OUR � HOW INlU0.Y OCCU
� ORUrvp[if0.MINEDISVECIfY� � qsnei111iW1l1
N' 200. ' � 206. 1 20c. M. :20d.
p_'_'_""'_"'_"' INIURY AT WORK
� PLACE OF INIURY �r �aw.c v�aM, sm[[r. � LOCATION �GT', VIL ON TOWN; pl
(vES/Npl � fwCiORV. OIfKf BUIlO1NG. RC I�FUfYI . _. . . .'
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_________________ ZOe. � Z�t. � ' i � . ' .
. I CERTIiV THAT IN MY OPINION, BASED UPON MY INVESTIWTION � THE DEC DENT WA$ PRONOUNC
-- AND/OR TME IN MONTN DAY
WISIiION, THIS DEATH OCNNRED ON TME DQE,
210 Ai THE PLACE AND�WE i0 THE UUSE(5) STATED. AND THAT --- i Zib. March 5�
[ORONER'S S�G ATN0.F . n O /%/ ^. ne
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PTY OR TOWN
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Ins[ant
Instan[
�wne rv.ruo� o� �rv�unr wwrror�o �� ...i i
JtD (MONTX, OAY, Yf
3-/�-7/
�ED (M�NTX, OAY, VE
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REMOVAL Is>EaM ' "
z,a. Burial ;x�n.I.0.0.F. Cem. ?z�� Princeton, Indiana ;a,a.Mar. 8. 71
' FUNERAL HOME NAME ST0.fR N1D NUMBFA 00. 0. i. D. � CITY O0. TOW11 sr�rE nv
zsa.Rendall Fizneral Home. 520 S. Main St.•. Princeton. Indiana__47_470— --
FUNERAL OR'S SIGNATURE — -- -- - — : rux[au aac<rox•s �wrmis ucwu r�uwu
� � i i5u � d�e.i]1
' LOCAL REG 'S � � — .. . ,_ � ATE R C . L REGISTRAR��.a•.��
- � � ' 266. / �
:;,�� '��� 1 HEREBY CERTIFY THAT the /oregoing Is a true and correa copy o/ the deatb record lor the decedent named at.item 3,'•';' -
"-- ond �hat t is rernrd was established and liled !n my oHlce In occordanc e p isions'�o/ e 1117nois statutes.'
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� _ DATE ^ � SIGNED -� ' � _ ' _ _
• . _ m � _.� •- - _ :. = .
NT.CARMEL REGISTRAP ,��.,. ` ` -
AT , Ulinoie. OFFICIAL TITLE � -- �
. _. . � �, �< - �_ _ - ..
� 71v odt�nJ rewrd ot tLb deai8 b perm�nmtb 111ad wIN lL� ILLiN019 DEPARTME[J'f OF PUBLIC HBAL7'f[ al•SnAn•�cld. CounY elerki �nd laeal
D�ewt�eni of bl e Realtb or�N� lapl rt[I��tr�ir�or�Ne �eountl�elirk �iLVI�W D��flful� e�lde n�In�ilecoarLh�nd pl�ir.Uo( Na f.c�+ Ne�relv ,t+ted.
� VS 201A, (1961 revi�ion) BUREAU OF STATISTICS — ILLINOIS DEPARTMENT OF PUBLIC HEAITH — SPRINGFIELD �
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