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Death Certificate - Hurst, Jesse Herbert_12/6/1978I i i. .. ..i._.. .... .. _. . . . , ,..f ' .\' . . ' � fLLl IN wI7H IYIEWRIIER OR LEG�O[E IRIMWG (�i�� ' ORICINAL . o i+.:F�iif T �_� _ . .)Ti�TE �F. ��i�i��.S......_ . ...w1uRr ' "' D[CED[HI'1 MEOICAL CERTIFICATE OF DEATH �«�i,�•:�o� ��a�s:neo �� . � ILLiN MO. J�f.��Gt wp. �� wUr1l� . '� � i. PlaLf O� DEniH . 7. USUAI RES�DENCE (�+c... ��.<.o�.e �:..e, u:.,r:i..:... ..,;d.+i. s.i... I I` I .. Siwfl b. CAUNn . •. SUfE InC.�13Rd e. COV�t�. � n ed�:u:�n.1 � . � Il11N01T ti� il�],��Oil � o INL�f awpwoh flnih o�d in Ciry, Vdlpq�, a Irrcwpao�ed Io+n �, [�.INSIDE <wporoi� PwJh oed :� Ci/�, Vllloq�, a IMwpov��d lo.� ` � a. • � a Piurion ' P inc o ' � :: •• � . 1 -- � , ' � d. Q OUI:IOF capo.ah I;mfh ond in •. t N IN t n d. p OUi51UE to�paoh Lndi yd !n �. l M4IH d� � M � �� ' o Io.mAfp mm� ......................... . �w ic w In lo.�.A(p mm..................... wr oc « a � 1' � :` Rood D;✓�rtr No ................ �....... �� Road Ohrdd No................... !/UK. � �J �' <°s (, nnME OF HOSPIinL OR INSTIIUTION V• �H�� Of w �, RESIOENCE nDORESS (S�..s� G No. w RfD. ad Im� OR:u) �'� "° +� 718 S. Race ' Ve�erar.s ++dninistration 32 da s � �. u.o� :. �,�o��.� o• �•��•��•. a�•. Si�nl l No. a 1J.0. �nJ Io�� OMi� Princeto� Ir 9 � :'. . :i . ' q.•D:d d.nd�n� ..ud� OH w I.vw! r[f � r(O � � ' �I �. [�wTE OF lu w��l (onrl r �. � p ]. r+nME OF �. lru p b. ui o� 1 <. t :� OECFwSE6 DUTM ' . � Jesse Iferbert Hurst Dec 31 1966 � � E ' S. SFX e. 4nCE 7. Mn0.81F0. NEVER MnRRIED. B. DnTE OF BIRiH 9. n6E (rn�.a.r '��"°•"••" '�°" "�^" c� Z w�DOwFD. qrvORCED (.p«f�r1 ��,a.e:.ind,.l � ' � male white narried 9-14-95 71 � ��' �''", �: F w Ih.USUhLOCCUFhTION IOb.1:INDOFBUSINESSORINDUSTRTII.lIRTHPUCE(C��Y��o�+a�a��V^�°�^�7)• �7•G'i'rc�o��ho� . I ovnny) ' � ' - � Electrician idest Terre Hau.e' Ind. t�.S.A... � �� 17, FATME4'S FUII 1�. MOTMER'S FUII m HAUE ' wAIDEN NAME � . d ta�il�em x, xurst • El�i�-W`� all�y , �� LL IS. M'moecro�ed�+erinU.S.Arm�dfoneJ 16. $OCIALSECURIT7 1),INfORMhN� /��— �� r.., s, r,�..e..� re:...u. ,, ee�., w,.-:a.l b. ADDNE55 �- , c. REUiIONSMIP i0 i "� O� CE•�r 2 DECEnSED � n. vt�icnt G�us DEnTf . VA }iOS ital mcorzs ---- � � �MiI.OG(MWASLAVSEDOY.�fnMiml�en�spry�.l: Is��,��W(C�.� �.: . W . Iw:C�vnl �ETwEFM 0 IN4EDUl! CAUSE (A) • G,'�ffJ nHU OE�iM Acute circ atory failure �LCCienly . , N ^�{) �.�«fi ............. . .....................................:................................ ...... . .... ..... � 7 � ...�.+\.r_� �� 1 � . . ' ' ' ...... � Lond;�;w�. onr. d.. �e Iq r.N ' i ' _ """'9°" `'° 2. ocardial insufticien • 6 month J-� �MUtiDERt`INGu. � .... ....ry........�..... ..� .:.............�..........................................::...................S...F . � y ;y p., � • � �,�,°� :•^ ' � . u �.,,,. �.,,. 7,�r�o cl o�is, cevero Several �MI ��. Oln( �GS' 1 ' 1�_ Q�MHIIWtNO nIN U M � lA D H IuiMK r�0� � M 0. R 7 � .1 N 41VfM IM IAp IIA�. y 'wi�' H • ' H IY�.N�tMO�f��l10A�lII�M� �Ob. ��M �rN�� / M��w� ' ' � �. { LL ' res � wo � • O ` u ' p� V� NOTE: If �n injury .n inrob�d in thf� d��th, fh� Coronv 1nud 6� �oGC�d. ; �. I � 71./Ae.ib�cM�1��Aw ournded�hede��o�Wlro� .IV .re �-'C. ,IV L� .tl�M'`1�� d��}x � • �� V.. yddeo�h ott�ned o� M„ Fw �h� iou�r� aM on tlw doi� �iehd abn�. • I liiG�CY.'Y.j:"Y.'Yt',yr intXX's: —I?:�.5.—�— � • . o !' �� i�-''%^�l r��l �.�,v atr � w.oe �iaee ! o � s;,�.��,o�....D.'ccs?�n:Ii:O'1ZCH.�......... ".........MA. s�cna ......1-1-u7 .............r+>...................::' N � � > Mdros�.......1/i�iy.�'irion�; ••Tl�l............ .......................... ... rno�o...99°. 21.$ ... . ... .... } �) ZJ, fUNERr�L UIREC � � ... I27. DISiOSII�pV: BUNIAI�G"C4^iS2�:—�" D��a�.�.J. .../... j� ��(� � ........................... SIGNATU0.E �./ r r. .r.. � ..... s I eeue;[er ;unset.P.atY....... ��Ci.VII:'FU;.::2I:L"i:..��E" "" ; . ........... A��Q%iS ... .... ..... ..........IILIVg LKM�! ioc�nor+ : v.sncsillc,..7ad. ............... Pri aceton, Tnd. h,�'f', :,.,..irco .�. -_: . ,.._:nr I � ... . . .. .... � ... . G! fn( 3.'�': J: .;.�Or3 N. Ir<r:.rd la . / (57qnrdJ /� . /{ " ; � I r,r.n " � G�• ' , \ � ` � I::N::—,•:P: t..... A 9 ^' � ''JJ / .! (.. /�' �I✓� �� __� � � � _� �L� . . . .. i�. _ RLOUL REGISTA�= � . . . .. . _ .�" • ' .�. , -,--------► - - - - '