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1 PLACE OF DEATH ' 0 S SRR v @'WQS
z ) | CERTIFICATE OF DEATH

COUNTY OF A R L COMMONWEALTH OF VIRGINIA

BUREAU OF VlTAL STATISTICS
MAGISTERIAL
DISTRICT OF STATE BOARD OF HEALTH

OR 2
INC. TOWN OF REGISTRATION DISTRICT NOQZ_M?EGISTERED No._ »~8J é

FOR USE OF LOCAL RIGIBTRAR)
OR

CITY OF il il oS i R 1 LI PRt e MR St AR ST L 3 ST. .. _WARD)

2 FULL NAME

(A) REsIDENCE. _ No. ST., WARD; g il IS s e
(Usual place of abode) (If non-resident give city or town and State)

Length of residence in city or town where death occured yIs. 2 O mos. ds. How long in U. S., if of foreign birth? yrs. mos. ds.
PERSCNAL AND STATISTICAL PARTICULARS MEDICAL CERTIFICATE OF DEATH

3 SEX 4 COLOR OR RACE|5 SINGLE, MARRIED, WIDOWED.
OR DIVORCED (write the word)

___L@‘Q_me_»g‘f_: = =

1 HEREB CERTIFY THAT I ATJTENDED DECEASED FROM
5A IF MARRIED, WIDOWED, OR DIVORCED

HE SN DT s '
(or) WIFE OF é\ 1927

16 DATE OF DEATH (MONTH, DAY, AND YEAR, WRITE NAME OF MONTH)

6 DATE OF BIRTH (MONTH, DAY, AND YEAR, WRITE NAME OF MONTH) L1982

T oo - 19

7 AGE MONTHS ‘ DAYS IF LESS THAN

THIS IS A PERMANENT RECORD. EVERY

AND THAT DEATH OCCURED, ON DATEASTATED ABOVE, AT#M.
THE CAUSE OF DEATH* WAS As FOLLOWS;

-

é OR MIN,

8 OCCUPATION OF DECEASED
(A) TRADE, PROFESSION, OR G é I ‘2 ééi ‘2
PARTICULAR KIND OF WORK

(B) GENERAL NATURE OF INDUSTRY.
BUSINESS, OR ESTABLISHMENT IN
WHICH EMPLOYED (OR EMPLOYER)

(c) NAME OF EMPLOYER l\M %"VV\WU& _&#j . 5M 2
9 BIRTHPLACE CONTRIBUTORY.
(SECONDARY)
(c1TY OR TOWN)
(DURATION)

(STATE OR COUNTRY) 18 WHERE WAS DISEASE CONTRACTED
10 NAME OF FATHE IF NOT AT PLACE OF DEATH?

“l/b&’g IDeia_eoen

11 BIRTHPLACE OF FATHER DID AN OPERATION PRECEDE DEATH ?

1 DAY, HRS

MARGIN RESERVED FOR BINDING

(ciTY OR TOWN) WAS THERE AN AUTOPSY?

(STATE OR CO_L_!NTRY)

12 MAIDEN NAME OF MOTHER ?i Z
13 BIRTHPLACE OF MOTHER T%
(c1ry or Town) ——*ﬁ‘M—m State the DISEASE. CAUSING DEATH, of in deaths from VIOLENT CAUSES,

H, oL
ate (1) MEANS AND NATURE OF INJURY. and (2 :
S(sTaTE on counTRx)Ri T IR DR e e S BENTAL, SUICIDAL, or HOMICIDAL, and (2) whether ACCI-

m
19 PLACE OF BURIAL, CREMATION, OR RE-| DATE OF BURIAL
MOVAL

PARENTS

14 INFORMANT L
/A Y EN 7
pooress) ALLYL Al 22o0228 —CF
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; REGISTRAR ADDRESS :

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SHOULD STATE THE CAUSE OF DEATH IN PLAIN TERMS. sO THAT IT MAY BE PROPERLY CLASSIFIED, EXACT

WRITE PLAINLY, WITH UNFADING INK (WRITING FLUID)
STATEMENT OF OCCUPATION Is VERY IMPORTANT.

N. B.