No preview available
HomeMy WebLinkAbout869242•OO .0 b( ate• oTTgnd AaP;oN 111lI11111// 40 4 0 A O 17 8 Q, Nhe,y Teas TeTOT33o pue put Acu SSaNSIM i/19:2Milly 3o App sTgg agOSnod ugof Aq aouasazd Aut uT pup aul azo3aq oq uzoMS pup pagTzosgns d, 3o App tial7eP sTgg GaIva pzooaz 3o aeggeut p sT agpOT ;Tgzao ggpap pies goTgm uT AgTzoggne oTTgnd agq Aq PaT3Tqa90 ATnp 'quapaoap PTps 3o ggpau go aTeoT3Tgza0 TET°T330 aqg 3 Adoo p 'gtnppT33p sTqq 3o gzpd p saTew pup ogazag sagoeggp qupT33V pup :Agzadozd Tpaz pTps uT agpgsa pup aTgTq gsaaequT zaq pagpuTutzag qgl?ap asogM spaap pauoTquauiazo;p egq uT qupT33v aqg ggTM peuipu Agzpd TP0TquepT et sT 'agosnod aTTTonZ gpgg s8T;T4z8o pup szane qU T33V asnods 6UTATAZns SP 'agosAod ugof 'queT33y uT ATagnTosge pagsan Agzadozd Tpaz pagTzosap anogp eqq oq aTgTq 'agosnod aTTTon'I 3o ggpap agq uodn pup 3o uospaz Aq gpgs •000Z 'gsnbny go App gq6 egg uo 'agosnod eTTTon' 30 ggpap 30 egpp aqg oq paap pips uT pagTzosap 8OUPA9AUO3 3o agpp agq wozg ATsnonuTquoo wagq uT pagsan ogazagg aTgTq pup 'pupT pagTzosap anogp agq go szauMo aqg autpoaq 'a3TM pup pupgsnq 'agosnod aTTTonZ pup agosnod ugof pips agq 'pTpsazo;p aoupAanuoO pips 3o uospaz Aq gpgs buTwoAM 3o agpgS 'uToouTZ 3o Aguno3 'zazautW9M 3o AgTO aqg oq uoTgTppv MaTAJTPa aqg uT (Z) OMZ NooTa uT (LL) uaaguanas pue (91) ueagxTs qo'I :gTM -oq 'Agzadozd pagTzosap buTMOTTo3 aqg 'dTgszoATAans 3o g145Tt ggTM satgaaTqua agg Aq squpuaq su 'egTM pup pupgsnq 'agosnod aTTTonZ pup agOSnod ugof oq paAeAuoO '99L abed uo spzooag 3T4p4sogogd go LSZ Noog uT 'L861. aunf uo 'NaaTD Aquno3 U 033 rI agq. go aOT330 agq uT pt0O9.I 3o paTT3 ATnp sPm peep 1OT1M 'agpp gpgq 3o peep Aq 'agosnod Tnpd 'uoTgpzapTsuoo aTgpnTpA zo3 'L86L 'OZ APW 3 agpp eqq zapun gpgs :agpgs pup asodap''ggpo Aui uodn 'MPT oq buTp1o30p 111OMS ATnp pup abp Tn3MpT 3o buTaq 'agOSnod ugof 'I 9 �Jdd 2Id :NOM dIHS?IOAIA LIS 30 LIAVQI33V D„14 "1O1 1 Q01 uToouTZ 3o AgunoO h syf�j .:U •3$ Z iZ69B 130 00 1:) N100N1 Il iiiV 3 P 38 bu1luoAM go agpgS 'TYPE/PRINT IN PSIIMANENT SLACK INK DECEDENT I a11lTX CERTIFICATE NUMSU CERTIFICATE OF DEATH 150 O U O 1 7 E STATE FILE NUMBER ALASKA DEPARTMENT OF'HEALTH AND SOCIAL SERVICES Re wRDER•ENO BUREAU OF VITAL STATISTICS -P.O BOX 110675 JUNEAU, ALASKA 99811.0875 ore RECEIVED SEP 0 8 2000 1.0EC00E511 NAME(fR,L MI05A WE0 nn Povsche Lucille Jean YEAR RAEK 16 MAIDEN NAME 1. SEX F 1 DA 0809 OF DEATH (Monet, Ds% *0 SECURITY O SE 520 -34 -2040 AGE-Last elnnd.y ODERI 67 511UNOER So. UNDER a DATE 0RBI (Month, y, th, D MS) 6 -19 -1933 7 TH OO E (SUM w *01(99 Country) WYOMING Mantas Dem Houle Mt,ures I E STATE OF DEATH ALASKA SW PLACE OF DEATH 100.050nhons: moo instructions on ofno. slON HOEP R AL DTHEPo Upsilon' ERIOmlselleal ❑.Ow 0 5.11., Nern. Ns1d5MS 0 5.T )9. IM Sp FACILITY NAME (II not lnelNllon, pro *imtend numoo0.. Allen Road and Comstock S6 CITY, TOWN, OR LOCATION OP DEATH Haines O 10. MARITAL STATUS NEVER MARRIED QUARRIED ❑WIDOWED 0 OWORC55 ❑UNKNOWN IL SURVIVING SPOUSE (ll wile, give mold*. name) JOHN J. POVSCHE 1 1 I g O 516 DECLDENT'S USUAL OCCUPATION (0lw kind o/ want 00n. .90.11 most el wonting ll/6 CO not vs. NUM) HOMEMAKER 1211 KING OF BUSINESS/INDUSTRY O 1kHOME 13. WAS DECEDENT EVER IN UA ARMED FORCES? re! NO ❑UNKNOWN 14a. RESIDENCE-STATE WYOMING /so CITY, TOWN OR LOCAT10( lAn STREET AND NUMBER 1 KEMMERER. J1326 1ST. WEST 194. INSI05 CITY LIMITS OR SETTLED COMMUNITY? YES N0 C3 UNKNOWN e 6 ZIP CODE 83101 10 M. WAS DECEDENT 0, HISPANIC ORI01N7 "TI, FNlpinq Eleak (SpWIh NO O /Y *e -1 /rie, sp*UIY Cuban, NMNel Vysl6 Meald Fwno IlOJ WHITE ®e+o YES apWty. aWelly 13. DECEDENT'S E ono oo mpl*I* N (lpa01h0nlY highest polo doy m ne SI eentarylSeeoary 10.12) 1 12 Cmuege tr or Se) PARENTS INFORMANT DISPOSITION Oil DEFINITION ON ODRA 11101 1 II FATHER'S NAME (FlreI, MNION% W0 JOSEPH r i m MRAZEI. 19 MOTHER NAME Anil. MOOIR •a5O0n Su5lety a JOSEPHINE! HERMAN 206 INFORMANTS NAME (Typ0/Pnnt) 1 JOHN POVSCHE 206.EWILINO ADDRESS (81s.5 and Numb., or Rum Ran. Numo.S Glyo, ?Own; SMONS ZIP Cody 1326 1ST. WEST KEMMERER, WY 83101 206 RELATIONSHIP TO DECEDENT HUSBAND 256 METHOD OF DISPOSITION 0 E.n1 C3 CremaNen Removal .Dom a1.M ❑0.05100 0 Olnor (S 2111 PLACE OP DISPOSITION (Name of omelet); Omnote yor WhatpMOy (ALASKAN CREMATORIUM 216 LOCATION -Clly or Town, SUM JUNEAU, ALASKA 99801 22.31 RE. OF FUNERAL SERVICE N d O INDUS SUCH 2211 NAME ANO ADDRESS OP FACILI ALASKAN MORTUARY P.0.133103 JUNEAU, AK 99803 0170 PRONOUNCING OF F ICIAI. ONLY MIS 24•211 MUST I/ COMPLETED ET PERSON WHO PRONOUNCES DEATH CAIL',1 OF II CATM 4 x yy r� **[[W x IS 6 c......,.. 3.d a VelllI ,9 plt. al lanot 0 'k 0r55eale M time 01 dnlN to eanl ly eau. 0l meal.. ass 236 To Om beat of my fmoar WEE dun immured M the llmgd 1e,.na place states. 1 al9Mlun w0l7U. 2311 DATE SIGNED M onti, Ogt1.d 24 TRANCE DEATH '6 1442 M 23. 'PRONOUNCED DEAD(Mon)R, Os„ rise 08 -09 -00 20. CASS REFERRED TO MIDI l EXAMINER/CORONER? 183 Yee ONO 27. PART L Enter IM aleauee, Injuries, or aempilmellons that O.u.W the 0eat6 De reel 1 rtl lba41f;e1 dying 5ren as mantas or respiratory a Um Only one Cause on soon EKE ',:,,,Art IMMEDIATE GWE[ (5(905 eriosclerot ic CAT, iovasdrer Disease L shook, or Molt Whoa Approximate Interval Dehmen Onset IL Nate 1 or °atlon vv rTl. Oln ndI AS resulting dealhl q ex n 0 Sequentially real conditions, II DUET° (OR ASA C CEO Fp �w x, any, leading tolmmcause. s cause. Enter UNDERLYING CAUSE p (dIN4e Or (nluty that Initiated A plt r. TO IOR AS A CONfEOUWCl OFK erellt moiling l �'b+0' <rt«*' S PART 11.. HER SIGNIFICANT CONDITIONS contributing to death but not mulling In the unded9np cause given In Pan L 2116 WAS AN AUTOPSY PERFORMED? a III Yea S., NO 256. WEREfUTOPSY CONSIDERED COMPLETION OF FINDINGS PRIOR TO OF OWES DEATH% ❑Yea "R-,D No SEE DEFINITION ON OTHER EIDE (:I „lirif 1 200 CERTIFIER 0 CERTIFYING PHYSICIAN (95050(559015np awn 05 4Wll wham moth*, *MIN has pgnounp.O death M40Omptstedl0m 23) .a (Check Only One) TO the DIM 01 my luoveledgs, Ease. 0601111116 due t0 Dm emits) and manner 00 stated 0 0 PRONOUNCING AND CERTIFYING PHYSICIAN (Phyoktion both pronouncing death NW oontryIng lo ammo 01 Oooth) t fi TO tea east 01 my knew.Wee, Oman 00cu1W M Ins time, d.te, .nd Mow, aa0 dpi to um cra00ele) sad .1rennor sa slated MEDICAL EXAMINER/CORONER On Ins bat sot .aamin.lUn 510155 vosoaMlon, In en? opinlon, death oocum2 el IM tmq dale, arid EMU, and duel. Me ousels) and manner as stated .]d1 0 ,1, 2815 DATE SIGNED (Mont,. Day, Tom) P ry I aMS.d e. r e I-Ca xan21ne1F S5 C M ae A' T• ropst, W L 00thM $E7 ;7AO0 T Anchore Alaska 99507 206 LICENSE NUMBER 1067 b� TNTudo1_ggad D LJJ Natural Pending Mold e nt ImeailOMlon Coale not Do S501d. eat.mrinel Xem50100 31, I `MANNER OP DEATH. IS OTHER THAN YNATURAL' ITEMS 31. Eli MUST O■ COMPLETED. 316 DATE OF INJURY (Month, CNN rib 319 TIME OF INJURY 319 INJURY AT WORK? D pia NO Md. DESONBE NOW INJURY OCCURRED? (Emilia onion motto, In MINN 316 PLACE OP INURY -AI home, Met. cannery, el0ea Ma. (Spool 5 311. LOCATION (Stmt and Number et Ru5S Rout Numbs, City or Towne SINN (:Ott Ol -P 32. RECORDER'S SIGNATURE 31 RECORDING DIETR1C7 3A OAT! MUD (Nentl4 0 E V5.101 STATE OF ALASKA ��U� \V \U 1236 1j }1 1 \11 REV. 1.92 J I CERTIFY THAT THIS IS A TRUE, FULL AND CORRECT COPY OF THE 9 AL CERTIFICATE ON .FILE IN THE BUREAU OF VITAL STATISTICS, DEPARTMENT OF HEALTH AND SOC VICES, JUNEAU, ALASKA. DATE ISSUED ORIGINAL- STATE COPY Str f» iti ,��tE� S S4 y r i) Il f Zt 4 (iil hANY A ff�i�l!t;�`J59