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Death Certificate - Rozika, Virginia_9/28/2006DECFDFMS &RTX HO. qEGISTRAT10N y� DISTRICT NO. KZQ FEGISTERED NU.V.BER Tyq>prNtln DECEASEUJJMtF �F��x � Virginia a,. �°'��•d�/�k���� COUNrvOFDEAiH as�'m"°cno�vs ,. Dupage CITV. T05YN. MP.OR ROA� DI! A 6,. Eimhurst STATE OF ILLINOIS Si�TE F�LE NUMBER MEDICAL CERTIFICATE OF DEATH Rozika 2 Female 3 January 23, 2003 �GEIAST UNDERIYEAR UN�ERIDAY DAiEOF81RiMryCtrtn.O�v.•EUp ewrr.� nRSi �us. w+s w�ms N. QCtOb2f 31 , 1 91 8 sa. so. x. se. TRICTNUMBER HOSPRAIOROTHERINSTRUiqN+uuEp�nO:wEm�E0.GrvE5iREEfuIONUweEa� iFnOSV.IXVwSLVUK�i£DOt fio. Elmhurs[ Memoriai Hospital �E4`�npa�ieri�"" MARRIED.NEVERAIAiv3IEU, YAMEOFSURVNINGSPIX)SE ��uWEnruuE,iiw6E� '.vw50E6OAR5fF�D�EVERwV.S I L YADOW'Tp,DN�RCED �SGEpM NYEO` 'VO(rE5fp1 � YYIClowea a„ 8 CrtY, TOwrv, MP, OP RO D DlSifilCT HO. u:5�0EplV COUNiV 303 E. Washin ton A t. 737 Bensenville nESV01Yes Du a e e ............. .�. 9 P ,ao. �a�. ,aa. P 9 SiATE ZIPCODE MCE MMrtE.BUCKwEPC.w OFMISGANICORIGW? I����+E��.��R�M.�4*Grv.WENiOwfiw.�el Illinois 60106 "°w``�'SVh�iie �y 13e. 131. 14a. ta0. [{ VO ❑ YES SPEpFY: FATHEP-NAME FIRST MIDDIE V$T MOTHEF-NAME FIPST MIDDLE (MAIOEN) LAST �5_ Arthur Harper 16 Evelyn Flohr WFOIi.UANT'SNMI.E �ivGEOUVAL1i1 REUTIONSMIP MqRJNGADORES515iPFEf�MO!qOanfD.CrvWiUVn.Si�:E.21q � ............. ��a. Kenneth Rozika ��b Son ��� P.O. Box 151 Hazleton IN. 47640 Z 18.PARTL ErcerinaEluases,ummpf�tio�vma�rauseou�eceam.DOnden:er�nenaceWytrg,ycnascaraiacarescva:oryartev, ��E����„X .......... Yack a Peart IvRxe. ti9 u✓V a+e ca�x m eaM ire. � ........... �.,�.��.�� /1�u,+e rn .- 1� : a�«�a,s, a!i O C4 rc��c� 1n IC�, c'i1C•tt. 3 cic,c' S ���n��� OUETO.OFASFCONSEWE OF ......... .. .... CONDITIONS. IF AN'! WMICH GrvE RISE TO (b) L �'It �t Q S L 1'� �- F-Ca i S LKNEDIRTECAUSE(d) WETO.OArSP I:SFWENCEOF STATING THE UNDERLYwG � CAUSE UST. c 4 ............. PAATII. oT. .�-�+vmmoe�w.vqme.m.vmn.w�y+:a.w«ry.qo�,..y.MnnnR:�. AUTOPSY ..Ea.wo.s.s.i.�s.v...u'.oa.o s............. N ............. �AiEOFOPERATION.IFMfY P ............. 20 I' IDNOnATTC40THE ............... . TSI1W W4HERAlN .._...._..._ 21a. 22a. SIGNATURE NAN.EnNDADDRES n�Dr. PLiti,l i /�3 /03 �.,,,�E��,��EO� b0. �`f0 OCC HRED HF�T� 0 TE/wpP{�CEnNOOUEiOTHECPU5E�5)SiATED. V �= ; ��EWFPIt.^) . . 5iS S. frla�n � v.cT , 1-o�.-b�,r� , TCI�h� r. iTFUNCERiIFIEH (nrtOamvrt) No :qc. YES �J. ' BURI.LL.CREMATION, GEMEiERVOflCREAUiORV-H.aME �OCniION pnoniowu 5*+r[ REMOVPL� Cvvl. 2„_ �urial Za�. Rosehill 24C Chicago, Illinois FU.YEMLHOME NAME STPEEi.WOYV4BEPMP.F.J. CJrypqiOMl ,t, Geils Funeral Home 780 S. York Rd. Bensenville IL. 60106 zse. VR2p01Rev. I n zza. U3G� -U G� l� y 7 NOiE:6�NIWUPI W 15 W VOLVFOIN 1M5 OE�TIiNE C0110NFA pq YEdC�t EL�MNEP YVSTBEXOLIFlEO. ORiE �uOw:µM.r.vE�w� ,,,, 1127/03 5'�iE NrvE0.LL qRECtOR'SllWGSlCENSE NU40ER zk 34-11894 � ��, �� � )��`IZ�f4EJ9ROGl4EJAN 29 2003 ��� 1 `, , OI PUCfC HP9iA-�N5KKI OI VI'dI RCCIXCI 1845EOON I9p9U $$iM'JaPDCEAi1fYJiE� � DuPage Count}• t� � Health ll! \'urJi (l�unn' Frtnu KunA � �.TL'i' DCpBI'CIT1Cl1L � 117ip�mnr. !(lirtuir b�N.c: Tlri.c is fn ccrtifc'�ltn! d�is is n tr�ir aiul can�cct tu�c uf d�c officia! rerord filed �rit/r d�e //linois Deparurrenr of !'uhlir Healr/r. � \ - `' " LnenlRr.i.(rnr :�'u� rnlit! �citlro« t d+e euibossed senf oJ DuPngr Counn' llrnith Dcparhucut