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° �"�^ ^=� REG151RATION �a� STATE OF i1L14015 •v�ec.
DISikIC� NO.
zecisrczeo MEDICAL CERTIFICATE OF DEATH
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18. DEAiM WAS CAVSED
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NAME AN� AUOPE55 OP CENTIFIER
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19, 1987
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1 HE'REBY CERT/FY THAT rhe Jorcdofnt fr a nue and conecf copy oJrha dearh rrcord/o� thr dered�nt namrd at ltem J, ond rhat rhA
recoid wei eitabllthed and /[Itd In my oJ/Ice In aecordanet wlth fht yrorfifoni oJ �hrlll noii Vfra! Record� Ac�. � .
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DATE � ����'� -- SlGNSD �_ � �
MARION ,/!!!nolr OPFlGAL T/T G CITY CLEAK
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The orlglnal rerord o/ rhtr drath 4 pumanrntly� flled w!!h rhe lLLINOIS DEPARTM6NT OF PUBLfC N.SALTN ar Sprin;ficld. County
cluk� a,d local ir6Lr�arr a: e aurhorirrd ro make cu�fJtcadont from copler oJ the orlgfnal rerord. Tht llllnol� r(a(u�e� p�ovlde thef tht
cutlJlcarlon oJ a dea�h raeard 6y !h< Dcpa�rm�n! oJ Pv6ffe Heelt�i, loccf ta6fiva� o� county derk �hal1 6r prlma Jacfr evldtnce In all eour��
and placu o/thcJacft thtialn im!
VR�:O/8 /1 S68j O�FICE O :ORDS - �5 O�EPARTtAENT OF PVBLIC H�AITN _- SPRINOFIElO 6i761
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