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HomeMy WebLinkAboutDeath Certificate - Downs, Earl W_4/23/19631. � o. b. c. e: 3. � ; s. �\ � _� TH RECORD , STA?E OFILLINOIS; ,-_ Nu'Aisiv` 'NOS • • ' :',; ".GORONER'S• CERTIFICATE .OF, DEATH, ���sTa�noN REGISTERED ' DISiiIQ NO. 93 �O NUMBEQ 37� ACE OF DEATH •- r .. . ...,. -- 2 USUAI RESIDENCE iwha.d.�.oudc.d. ilmnarro�,.«dmc.b.ts,ode;u�o„� )VNtt I'.' '_ .1 0. AAiE b.COUN7Y • l+►abash COUNTY,ILLINOIS " '. y{�(lf$Yj$ Gibsan wth r�l; Ploce ,,. . .. c. Residenre was - �"� OUiSDEary�lue�e�df� .......................'......:-.:..�.TOWNSHIP. ❑OUTSIDEcfiGvTSmdm:..:::i.:..........................TOWNSHIC. �INSipE cEy li=0i eed in'IAe adY: uAoge. d Imrn ncseA o1 ic � � " a INSIDE ciY limd� cnd ia lSe ciy. Nlape. �n lown mrd o12d. iY,-VILIAGE,AR��TOWN- .�•`:•i�d.LENGiHOFSiAT'IN d.CITY,VILLAGE,�ORTOWN� - e.lEnOfnolRESiD[NO _'" • • • � _ Ib o� Ic � AT Zc or ]d NAME OF� .� o. DECEASED SEx 6 iv�'a-..� . M81P. , i�le' •••.••••• einco n✓vec�a . . . 112 West Oak uoo�[i c. ium � a: DATE OF � ~-. ' DOl'mS OEATH . • NARRIED, � 8. DATE OF BIRTH �-� 9, AGE ���+n [CED (specify) - � . Yl. ", ., bN hday _ ondsmre w lareign � StOP@ I7.1J.YlOS.B _• J , ' 1 �� ION A FAPMJ YES ❑ NO � IONTHI IDAYI IYFAPI 2 2 5 1960 i/ vMar 1 vem II mdn ie 1ra onrx; o�rs xaunsl ��n. 13. FATHER'S FUII - ..._ �a M.OTHEP.'S FUII -+ '�. 2 � . '. • . , MAIDEN NAME . . ♦ __ i- ,T �': _' _" NAME _ ThOID8S DOWIIS� — MH HB7.fiD3A� g .\ . 15. Wos deceazed evw in U. S Armed Fmces� I6. SOGAI SECURITY q. W FORMANT + ' � - d tl��. no, o� vntno..�l 1II yn, p�m w. o� dak� d rcel'" . NUMBER �� �. a. SIGNATURE �. � � �' u� - _ . � r` _ . _ _ ' _ Blancha Dovms " ' • m � � �Q''-;,�, . '�%' ' � � ' b. ADDRE55- c:�REIAHONSHIP TO , � � 1 I8. MEDICAL CAUSE OF DEniH •� Pj'j.i1CP �OIS IECZSAIIB ��YL ED ' p PART I. DFATFi WRS GUSED BY.[Enter mly a+e mvte per line lor IAI, IBI. cnd ICI] � . .- .- . . �. � � - - . - -'; ` 'r - ItJTERVAL BETWEEN s + •�••^'-' "� �IMMEDIAiEGAUSEIAI � '" � ' � ' � . A[JD DE TH � ..... � ................................:.:......�oroTia�'Y...T.hrom�}os�s.:..... ...:.. . �..�szan�. 3 c�r�r;o�:. �r,M, ' . ' � � � doeto181 . ........ ..... : . . ... .. .,r wFich'Beveriseto 1 . . .. . . .. . ... � �he abovelMMEDIATE ..... .................................. .. .._ ..............:.... ..... . �- :.....- .�.. CAUSE IAI. s:ating � .. . . ♦. .. . . F � IF.e UNDERIYING � due ro ICI "' � ""' "' ' ' " � "" ,. � ' ' - ____'__' ! . .r' ._2 '_ . ....�...�..,�....�..�..i.'.—_ __ __ ' _ _ . . . .." ' ' ' ' ' � � . .'.v;.._ . . .. __ .. . . . _ _ . . _. . - _ . " . . YES❑ NO�..,� Oa. ACCIDENT .(specily) 206. DESCRIBE HOW INIURY OCCURdEO (Speci(y NA7URE of injury vndr� MEDICAI CAUSE, item IB).. ' --- SUIODE - , . ......... ..... . ... _ ........ ....... . . . ... ... ........ ...."..,� ... .. .. .. . .... .. HOMICIDE ' ��. .................: � ....................................................................:............... . � Oc. TIME OF lxouc) •l�oxixl lo�r) lra�xl " . - INIU2Y -.... . _ _ . . . . . . .^ � " WHIL'��T NOi' WOQK ❑ AT.W' lo. Upon nedicoll�+es+ o�iE: sii 2_2 -6� ��, 01j�a1\�\D�,e \ . \� k. PIACE OF INIUAY fe.9.. i� a al�w� hoea, 2IN. INIURED AT (GiY, TOWNSMIP, OR IOGTION� (COVNiY) lSiQE) _ . Iwm.lvctwY, um�, d(k� 6k0.. Ncl . . . . .. . . . _ _ .... . . . - . _ " " . • � this deorh was cdused os rtaled obwe. 21 b. Upon official imesfigation I Iind the persm dezaibed died vt slatad abwa• ,..,. , .. . . . _. . .. ._..o.re: � smxEO: - - _ 1� tln��nC M.D.p�YSOINIRN. Z/Z�7/(]O Vlla.g• L�.� Miller CO20NEk �DY.... �FIRM NAME.....'..' � � ��ADDkESS ......... .'..�....._ wU ... .(:. o - ........ � / ` SIGNATURE i-. iA. �...�?YM .....:................. � t Qn �. . . �Zid �,� a : . . . . : . . . . . � �IICENSE�— y � 6 . ....... G: Colvin N•...=�, S39 ����•..• '"'' � . 'Richard P. Fearhelle �°�^��`�°'�'° a�:v�'� � ILLINOISDEPARTMENT-OF�PUBLIC'HEALTH--SPRINGFIELD � �,�..,. �\SS�GS- � ���`• ` ��j�P �ect copy o) the death record /or the decedent rzained at �uem 3 and [hat'thu.reco:d � I6� QF pod • pronisians a� �e lllinois statutes re(ating w[hc reg'utration oJ.6irths, still6irths and ��� ZI2��J��PJ� aJo C�ti'`tY . . ld o`n�`LO n e�� ,-• �,0�'� oieE. o�� p� �IG\t w++.+�Q� J� � n9 °n : ' . ¢j � ` � i'� a�+�e tn '�, l _ JS' �t 4 fi Rpeistrar. Dist. 93.� ,Fl `e� �r � � 2� I• .Illinois . OFFICIAI.. TTTLE rc f.�� � .1� � !IS OEPART�IE]T OF FUPLIC HF.ALTH u'Sprin[b��d. �vvp dv�k' •�d �°�`��'KUinn G 6�� � 1v� q b< Illivois mw�o .p�o.ide �M1�t �he «rtifice�ien ef dee�6 ��d b� �6e Depenmw� at Pvb�'� ,`�RF, b�h�a` � �g ��AY b��r?evae iv dl mnm �nd Plsen of the f.cb �Lezrin mmd. . . . . � • . . Printed by the AnNorits of thc SUte of Nivoia ps<=5 � _ 0�9�0� �J\I 75717-7�OM-4-56 �T3 �a oth i _ �!` Q` �Q` ``� u e �� 6 � � v J `° �`°m°°°5 �}�� � b, svod ge `r4"�' l� . a ° <`,�`'s o� QJ�`�O l�`�� � � 1�� Oa� o \� �� \° �'�Q Q � , � p� a �\ .l r