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Death Certificate - Miller, Charles Edward_10/25/1984Cert;��c� Co�,� � of a De� I�ecor� XC: 0542312 "O' QEGISiRAiION fjo ^ STAT! OF iL�IN015 •���e��� DISTPICi NO. Q V eccieiERED MEDICAL CERTIFICATE OF DEATH ,o.a.,�r., r... tMI.NlNI MS I �+Kb�. � ;41 n I���S9n1 owxa ir � �S��UC11(JNS _"""_"""_'" ..... _." VH I �, Marion Charles Ech�rd MIId,ER Z Male 3, October 22, 1984 16WOpDESCCMT ���yqi�p�� OA BFTH/MO.,owq�uel COUN 0 0 N Art�erican 5,. 64 �,, ' ' 6, June 5, 1920 ,a, Williatttson ON MER INS U -�QpF[i�iSS�vue��rCP. clv[ 7pg SV.O�!.FINST.uu¢n P!0[CIl�1 RM.Iw V�TI[• xVA M2d1Cd1 CPl1t2T Tnrv-�tii nl .,..�.�. ,. �. a.� ,. U.S.A. ,o, marriea Maxy Shanks .... �,. Mechanic � Auto Garaqe iS�ECIFVVE50RNO1l�eS �3a_ WW IZ � PESIOEN[E si��cr .�o n�ue�• cirr.roww.twv. w �p�o wsmicr �o. '"Ei°/�HOi T' cov�r� sr.r• 1123 South Stout , Princeton ,� Yes ,m. Gibson , Indiana FPIHEQ—NAME ��esr .moi< <•s� MOiHEQ—MAIDEN NAME ^�s' •�oou uv �s. ��h�. M�R ,6_ Marion DEBO[Tf m�aeu�rvr r��we Irn[ on rniwil REUitONSHIP MAIIING ADDRE55 �suttr .4o wo. o� ., r. o., a�. o• m.., nrte, nq „`I�a�s C��nden ,,,Med/Recs „YA Medical Center, Marion, IL 62959 IB. OEA7H WA$ CAUSED BY: (u�er ow�. OnE uuu .0 u+� �o� 1.1, lel. ••o Icl) �u.�n p��v�.�o ou�. fAGi L �••[oui[ c.uft �a� Congestive Heart Failure I�m�iate ov� ro o� .s • co.uovu<i on ".'����,• �� .,•. ro� Acute t`t�'ocariiial Infarction 0.3 s ._,�. ��.. .�,� ,o -- o•.,< <.�.� �.� Y S:�i�*G IA[ VYOI�. DVL i0 O� �3 � CO�S[OVL�C[ O�: "'"° """ ""' ��� Occlusion of both coronazy artesies Weeks % PAPi II. OiMEQ SIGNIFICANT CONDITIONS: co*a*wro tw*�nvu�.c *o u.r�. �vr wr uuno ro uvu u.�w �v r..r ��.� AUTO75Y �• 1[S. • Arterial Scleratic Heast Disease '•"„°' •• '•.•. •"" ,o_ Yes ,e. ���Yes � ?Ja. ' I'10b. i ID�OIw�,TTEnO TNE �ECE/13ED �.�DL MEHwUVEOt� ?�a ro iwc ecsr or ur Rhowv�oc�.oc.,+w o }OC. rE5 ❑ no ❑ (MOMTN�01�.�[�MI wN�ORONEPO114fOICAL HOUF OF DEATH My.���� �t (R�Y�NCN NOTIfIED) IA..WIJC1 ZG, 1984 i3oECIfYVE�ORM01 � Z�C. 3�05 A. �.o• rxcriu[,o�i��noe��«�woar[rore[c�us[lflaierm. O�TE41 MEO r�o.,o�r,re. �" __-- 22h �'�2i� 22 Ir�vc on reiwrl ����N01] UCENSE NUM EN I�hishtaq Khan, NID, VA Meclical Center, Marion, IL 62959 zzc. )F �TTENOIH6 PNYSICIAN IF OTNEN TN�N CERTIiIER (rrac on v�iHr) 2�0�....BllYld�. I7�b. 1 . � fUNERAI HOMF NAME zso. Colvin Funeral NOT6: IF AN INJUNY WAg �NVOLVED IN TMI� Of�TX TM! CONONER OR YFOIGI EM�M1Nl11 MWT Of NOTIFIEO. ; EMAT Y—NAM L A tON cv. o� �o�x wn� AlE 1•o+n.o.r,.u. .F. Cemeter �.�_ Princeton IN s.e.Oct. 24'. ae��n ..o .o.�e. o. +. r. e. u+. o. m.. snn ne 425 N. Main St., Princeton. In� iiC�.��� tv m �/1 I Vnl[ 4t Vj{� lVlAl AS[�tsIpICAC1��O��e.O�qr4�1 �ba.► � �/��i -/ ' , ��d�t,.��S � �' ]bb �//��(K �7 ��9� I VR200 REV. 6/8Y Illlnols De artment of PuGllt Heallh � OfflCe of Vlbl RsCOItls (B�SE� OM 1978 U.S. ST�MD� CCNTIFIUiE) ___—' —' . . .-. —._.�—....._' - _'_"" -'_ _" _"'_.—_'" i" . I 1/fREBY CERTIFY' TNAT �he Jo�edofnj It a �'ut andvtonecf topy oJ tAe dearh rerord /or the deteE*n1 named at f�em !, and that rh4 ` r�co�d war eim�rhed and Jlled !n my oJ/!ce In occordance wfrh rhe prorlilon oJ rh� /!1lnoli Vlmf RrcordrAc�. - � � i DATE __..(� ��1�� /��� SIGN6D �/rLlyi°i?l� `_/:���.i � / ,. .q T — M�I�N . If!!nol� ONFIClAG TITL6 ` �CITY CLERK � _ _ Thc orldinal rerord oJ �hly dratA l� pe�manenfly J/led wlth fhe 74L/NOIS DEPARTM6NT OF PUBLIC HBALTH af SprinrJield. County rluk� and loral n;6t�ari are aurAorfred ro mate rerrfJlcatloni J�om topltt oJ rhe o�fginal retord. Th� /Illnofi tmturrr p�ovlde �hat fhe �rrrlJlcatlon o/ a death �eeo�d Dy th� Oepa�tmrnf o/Publle Nea/�h, loea/ �ea4ha� o� county clt�k ihall be prlmu facte evldenre In a!f couin a�d r/ece: o,�the Jeett !h:rdr. t:�t - VK�:O/B //968J O►FICE O. • :pRDS - '�5 DEPAqTMENT OF PVBLIC HEALTH - SPRINOFIELD 62761 � /: . , �