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Death Certificate - Jones, Hazel_8/7/1975' . � - .��YRa�S3:.C' ... -_ ' . � . . . . _ . . ' . � • . ___..._..___ ...___._SFRTIFIFA CaPY OE I�DEATH �EC08D _._ � , COUNTY RECORD � �:FCE]i�i'S ; d',l;n nJ. 1 t. "PUCE j'labash STATE OF ILLINOIS Si��f I�IE �+UM6EI MEDICAL CERTIFICATE OF DEATH o�s�+cr o� o. Decv. raok pla:e � yfl pU::�DE ur b.nn ee! w .........:........................ SOWNSNIV. p � V S:CE W. I.nu. an! :n ine �a.. .diope. a ro�n nomed a Iv. c C�7Y. Y�ItAG:, 02 iOWN ' d. tEwGfH Of S:�r IN �0 �c :"•It. Carmel j� 4rks. e.hAMEOF u�iw::,ncm+a�e�.;✓.a<�.n•e,�n.� LtFnG�nOVSiwr n0571TA1 O�},rei� �u �^ ��sr�,u��oN ^ a�uasn General �•tks . J. NAME Of � a. ���oSt� b. udJOtEI DFCE�SED I1�7i+L i emale � S•r_A - ����:arr� �3 � USUAI OCNPATIO:� i��••��^dd i0b. cwDOFBU5ivE5 Indiar_a �� � ''� " .. ." ' � � 'EGiS�i�FU � �eQ:UN6to 6 �� �vW.o�.,n.e..�.eda.oem���oa/ -. .COUNn .'/ ', G1bSOn'-' '_/ c.��e<��. ..a� �OUil�OE ��r L.�� ord :n ................ . .......... ... ... .TOW NSHID. iNSiDE ��r i�m�� ond �n rn. <h. ab ., n ro..• ro�vd n]d � . CIiY, VIIUGE, OR TOWN e.�EnOla o�Pf5i0FNCE � Owensville I,i�e STQEE i ADDQE55 q. D�d dxede�r ro�d� �'- QN /� IAiMi 3�5 id. First st. ,E�❑ �o�J � a�usn t. DATE Of �MONtn� iwn nt�u;� JO?�t"L•'S I oEA'" I 10 1966 � D�iE OF BieTn 9. AGE !� rw� i ��d.� . r.a, i,�a.. �. ti�. lpyp..lA_011 O�lw1 D��S nOV�f •le. 1.�_2_l S,jQEi ' F�Q --- -- - - I . BIiiH?UCE (Ciry ond sto4 a�aaV^ �^�O') �7. Gnrm ol..hol i2m.lwmpm✓d�oLnpl.b.�..n . ' cwnny: �'°'••'flo:aestic domestic � Gibso:� Co„ Indiana USA Z 13. FAiHEi'S FU l I�. o.tOTMEi'S fUll - NAME � ( MAIDFN NA.NE � Giliord G, ttiallace Janey ICitcnen s 15. :'/o� deuooed r.er in U. 5..�.�med fate�� 16. SOC��I SECUO�TY V. INFOQMANT �"� ' ... ttn.rw.o�unuw�M plju.p�•�.a.ado�udv�A NUMBEC a. SIGNATU�E m '+7illis Jones � no none b. ADDGESS 30 N. F1TSt. St °' qEUnOU5n7 TO `. 18. UUSE Of DEATH - Q472I1SV�1� le Indiana DE'1�15 Oi T?3 � �P�Ri6DE�iHw�SC�USEDBY: [fnnrm�roneaous•p«Gne/«ui,�BLond�C�.] ��:iE2YAl0E7wEEN W CNSEi AND D.ATM = .� ��'� 1MMEDIATECAVSE.u1 acute coron�ry..occlus.ion � ,,,.......],.,�i.av....; : ........................................... ..................................... Cm1b:a�i. f!'a�y.� . � dw �o 181 ) � ZwE¢hpo.er��eio' � COSOY1ar�/ arter�> ieeac e � Qrhe aSovetM.h1:DIATE �...� ....................:t.....1.............l...�...`l.....Y_...................................... . ..........'j......... ; ' r CAUSE IAI, qannp :, � Z Q �.ie UNDE�ITIIVG dva io ICI V cwulo��. = PA4T II. OiME2 SIGNIfICANT COND�TIONS CONTiIBUTiNG TO DEATH BUT NOi REUTED i0 ME 1E3Mw�l CONDIiION Gi�EN IN PA2i iW. � � � Status� after caolecyste.ctomy .............. � .:............................................... . ... ................. .................. . -. 19. AUlOPSY� J' O ,a muTtinle renal embloi resgr] �o �0. If ANY, IN PAYT I OR PA¢7 i� � •?l. I heiebv.cmtNvthoN auenE�d �he dxeoud Irom '��G l . IN� . ro l�l�� . 19y/jt_. ihal 1 bN �m. iAe deceaud oG.� .; on ���-Q . I9 6 b. ; o�a a.a�n ���,,.e a� M.. fiwn �ne cavio end m the dorc i�ar� obo-e. P10NE ' DAi: SIGNED ADD2:SS `���}3�'J � - �• v0�:: Ste M.D.L L' + S`a . �� ..�..o�� f�� - � 1 n' l ��] , 6V... il FIPM NAME....Fr.O� llPr..C�i1:.�T.'2� .�.O:AB............ ; DISPOS�TION: BVRIAI�FEMOV���CREMATION �DAiFI....�lG�.. ] � U CEMEiERY......U.,1,5%T�C. . .......................W�ADD2ESS.......J�9...5.�..1'Sa:.Tl..�.il........................ \ ...................... � zW Ow.ens.vi7le...Ind�.ana............ 's iocnnoN.;..Ow�.riS.Y1.1,18.�.,.�.Ad7.ai1.3 .............. . �" D 1tC W SE , ' . ."� $IGNAil1RE� � 7 tl �' � p rvum5'__ ����956 IIZl Ra<aned lar ISipned) _______ � nr�o� 1-12-66 James R, Raibley - ;��,��E�;;,,,,�' i -� �355: VS & R 200.1--BUREAU OF STATISTICS--ILLINOIS DEPARTMENT OF PUBIIC HE.rITH-•SPRINGFIE�D 1 HEREBY CERTIFY THAT the /oregoing is a true ond correct copy o( tne deoiF recc�e �c. r:• J.c.m^�r r.c-..d o: iie-i 3, ond fha�.this record was_ established and liled in my oflice in accordance rt •'+.�/p:�..:s =..' �• 1(.,.:u�s s:atures. /-7 � ,�.1. ,� �...�- - �' �. �'-� � .�7 / � — SICVED � ','� �- `�- - DATF . �--.. '---.' -. .._ - �T iit z Carmel , I�linois. OFFICIAL TlTL£_____ _t'3�' S°' �=_=— The o:i¢inn: re<ord of •hi� devtn ia perm�nen[ly 5:ed �'I:A :1:< ILLI�OIS DEPdRTS1EyT JF Pl'BLIC HEAL:H �: 5.�.: e:d. �'+�vr c�<rtie snC 'xai inuv� uro ociSOrixed to me4e aertifiu[ion� (rom ropi�� of :1e eri;,lnd emrd. Tte .i:moi. etetut<� Drovide eE�t :�e :�v:etaa o! � Ee�:h recort Gy :hr Dewr.men[ o( PuEll< Rea�ti� or h� Iaai n¢i�vv or tA� covn:Y d�ri �h�ll G. nnm. (�ci� a.idme� in �ll court. �nL��.l.:e. e: Cw facu �Ar.ein ....e... V$ 20)A (196i revision) BUREnU OP STATISFICS - ILLI�015 DEPARTMEN7 OF ?U6LIC Hf.ALTn - SPntVGFIEL'J I 1