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Death Certificate - Cotner, Carl H_6/29/1981��+�,"�y � . HL( IN WRN f Yf1N'R;lfR OR i.FG�slt, VRiNirr�G • 1 �. �'M � , . ' � ' , ��.> ' ' ORICItjAL ' ' � +� o-'� � �� I( STATE, UF IlUW015 sr�re nu , `��+f�''yi)'} . , � NV41F1 .. F` I o�tto��rs MEDICAL CER7IFICATE OF DEATH �FCisn�nor+�G � I�IIN NQ � DISIIICE NO • I � i. v��F o. oen�n � . _ , . s�niE � n,�couN�r C003C 1 b IILINC115 ' ' a l! O �f �. INiIDf tarpo,nb limih nnd fn Cily. Yillnqr. or Ivoqqrnr.� ' Chicego . '6 d. � OU�S�DE �o•po�ar.��:�.;h.e+d �� • iivi:i IM Ir �-- — " 7wn�Alp wam� ..........:...........:. � _.. .V Rad 0l�b;a1 No ..................... ' . . : � Y 3_, 6v i, NAME OF HOSPIIAL O0. iN$iI1V110N' . o� ��• 1 .. __.... , F ir� r �•; P:eubyterian- St: Luket 3 + i ( �' �. li •o�'�n no�o��ei o..�+��d.bo�, p:.e Sn�er � No. o• � 1 .�..�/V � �.+ . � , � �� . ., �I r. u>uni Kc>iurn�c �wn.,.�a«w�.a.r..a. n;�,r:i„r,e.. �n�ra..�. e.ro„ • •. SIAII � ' . ' b. COUN11 . . odmnl:enJ Indiena I aibooa " r„ �Q INSIDF roqro�ab fmlh o�d �n,CirY• Villa9r• oi 1^<orporaled io.n , Fort Branch. ' " � d. (J OU7S�DE mrpowb.l;m;ry a�d ;n ' •. llN Iry. e� tF � M. ' �l 1t a 1E . � TO.mAfp mmr ................1.�.. � Rond D��Ir�<� r+,....:.:... � � . .. `,1 � YE9PS' . �, NESIDE�JCE ADDRFSS (Sr��rr G No. m RF.D. ond vo✓ OM,��) . 200 S. Waltera,, '' . � q. U•d de<.drnl ia:d� ON'A 1A�Mt . ' Yff � ' NO '� 1.—_ _'� 1. NAMI OG 's. �M1�Sq .. . ' b. Iu�UU41 . C. IUS I .. ' �. O/�1E OF .IMONIHI IOnr� . �i(nq bECUSCU : � ' � DEnTH Ca'rl H. : Cotner October 12 .1 6j;_. , ��,J,_ 5 SFd j A,:QACF I MARViFD NLllL0.4Jd1RR', R. �MF O� BIqiH v, nGE f:� �an ��tlrr�rw• vMrN�/u�, 1 � .w�� .. _ F ' ... , , �auAQ �.d�,i»...,. . ieJesn� 1 :a .... .,. , male' i+hite mnr e�� 4/6/02 � W �O.;USWI�OCN7nLON � i06,K�NDO�BUSwFSSCaINOUSiR�ii.�,�?UCElC+�ra^d�ro�ro•�o�dq+aounhyJ i7.C��uno�.M�. �� oal�esmad'�1. birch plor+ worko' Indiana lf.°5":Y�: , �'. ' il. iAlllER'S GULI�,. ' . .. . . . i�. M01HER'S FUIL . . . • , . . ' •. j NA1'F�::.� �. ..... � . . . 1.1AIDEN NAME ' . .• �:,, .,,,: .;:;Jacob Cotner Aana Mc Monigle •.__._— :,s W�.o�, i tle 1�.'S Ar�rdfavi) ,e So��,;�sf��R��Y ��. ��,�oRM�N, c er � �� i �• 1�G' w e, ae,.� er u.. �r) NUMB[N �� a. SiGNAfU�RF '�q�—� '� , .� C.�._ W i /� : � ///1 ' �. L+:inb� � r� �:f�•• � U��1 NG(,✓ �✓ h. [QR RE$$ —r� .. �c. REV.TIONSyIY lO i, . ,� ie uEUiUlCnUSEOF DFntFI ---- �---.-- '1/jj W• CORQT'906 PBTIMa7 . DECEnSED .. Vl�� s�•��.ol.��wesuus�oe�.ie.,.,a��.e•.�<., o.,,.. , � � eD QS_dD� �: .�,�e��e.eKll ��gQ _ � .� � � N1ErvAl IEiwEfN� O I� �� 144�D�AIE c�us� „�. ruptured abdominal `anetu'yom with recto . �� owser nr+o oenw � �,�� „ ...,.;. '.,.:,,. peritoneal bleeding .....: i.,. :,.. ....... t____.—_. � cae,r,o„i �o. „�r . � . . .. ' . . , , . z.n:an �p.r nv ro a.. . . . . � , � , . . � . ' � in�ota.rIMMEDIATE . . ' . ' .. . ' . � . . � ........ • � CnU:E Inl. ✓or,.q ................ ........ ... r. .. . .......................... .................... , .... . ... . . ........ :....: 1••__»_— � rn. UI1DE4lYING �o.. re itl � • . . '• . .. . . � � � • . � ' , . . u cauu I��. . . . � . .. . . � ' � � ' . . " ' . , ' � � • � I�I li, 0�� S� NIII AMI Np� �ONS CONII�IW �NO O b A �I ��U � N 1 FIh D � MINAL NO�II N O. AU�OPfY) �� ,� ' G�vlN iN JMI ynl � , � , � ' � , ' ' . � ' . , � .y , � . �....__ �n IV�.o.urroru�nox�v�wr IVb, u �.��a�o.a.�..n. ' . , . . .. , ' . „ u - . . '' YES a. NO O�' ' ,0 � �.�. � ' . . ' . ' NOTE: II �n inju'ry .n inreb�d in 1h{� d�dF, IF� Coranq muil b� noK(i�d.'_,'...:-n . • .. � . •. � � � cvi . rc 71.1�«ib�tMhl�iAOQrla�h•dedrAede<emedlryn__l�_.IV_V�_�.r�� 6 k".�,19vJ'��,iAa111ml;iow'iAidKemdoli.+'. � = y�__.__.LC� " ' . 10 .... � . ' . . ... 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' ' LOC�I �iYL�f]LLRZp . �� i . �- July 23, 1980 STATE OF ILLINOIS COUNTY OF C001< � SS CITY OF CHICAGO ) 1, Hugo H. Muriel, M.D. Local Registrar of Vital Statistics of thc City of Chieago, do herchy certify that I am the keeper of tlie records of �births, stillbirtlis and deaths of.the City of Cliica90 . by virtuc �of thc laws of thc State �. of Illinois and the ordinances of the City of Chicago; that the accompanying certificatc on this - sheet is a true copY as a record kept by mc in pursuance of said laws and ordinances. 0 T/tis Cerrijied Cap�� VALID Irl�en MUITICOLOR SEAL And BWE SIGi\�ATURE itre = a JJ i.r ed.