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J Edgar Hoover — Part 18
Page 2
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Washineton
KTHERT) ADDHCESS Cif rarel, give locatiun)
| 4936 - 30th Place, N.W,
Ie USUAL OCCETVIION (Gre Lind of woth done }igh KIND OF BUSINESS QR [1 BIRTHPLACE 12. CITIZEN OF WHAT COUNTER -
dure wort of marke ttfe tora if refered) IND STHY (Stair bien" frountry)
_....Director 2 0 0 LL $1.2...) __) USA,
Wu Fadiibars Nast Rh, MOTHERS MALDEN NAME “NAME OF BURVIVING 8POUBE
i Dickerson N. Hoover. Annie "', Scheitlin nove _
J is baer a ds q SOCAL SECUMEPS NO UTa INFORMANT RELATIONSHIP TO BPECLASED Wh ADDILESS Bireet City ae
Ag Apa TTL Helen W, Gandy, Secretary, 4801 Conn. Ave., Nw, dash.,! x
16 CAUSE OF DEATH: tbeto erty one couse por line for (a), Cb), aad (0) E interval Between On:
PART 1 PATH WAN ¢ aU shar BY. I ape Death.
IMME DEAL CAUSE Gn) pittaite cucdncnieelan clan
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Pak 2) OTHE SPGNTRICASN TS COSDTILONS — ccontiiluiting te death lal net 9 AUTOPSY ? | tk.
foatel ty the fora lisence conden goes a pal Dad YES OW NU
es Tn. 7. Ts Seen
7. DATE OF OPERATION am CONDTTION FOR WHICH OPEHATION
it Ves, Were Findings Copmudesn
) Detoanning Cause of Fientl”
MEDICAL CERTIFICATION
1
, wee Wi WAS MEFORMED
pO MERE RUE TEE SDS Seu atl Bae Was PRIGFOROALED)
hap ee ee ett suteube, roca Tu. HOLE AND PATE OF INJEGY Month, Day, Yearp ate. DESCRIBE HOW INJURY GCC Ru: \y
| eae et oactied mandate protest | tEater setuare of Fegury in Part for Past fio
M
eee we ee ee ee pcre Are ae ee nem
Thi INTO RY Vb Welt [ fle PRACT OD ENS W C40 Heres, Porm, Factory. ] 2 LOCATION civy COUNTY STATE
espe. bes our Ne) Street or Oftee Muildiny, Bie )
2. DATE SIGNED
i ‘. I certify thut (1) Ghis heapitul) attended the decoased from _ 9 -. to . 18. ._., that 1) (wo) ie. st
| saw the dococsed alive on . ._..-..-. . ., 1$...... ond that death “occurred from the causes and on the “date and hour ateted abere.
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SIGNATURE .° 7
Ca MEDICAL STARE
: PHYS. *
pees Cee STENTING
PUKREC TOR CT]
Tl ADHGIIESS
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é2 0 PIDY SE GAN .
PU ONAM A Tepe James LL. iuke
para i
CCutw, dea, oF counta)
ic ROOREAT. | 2 kek { hh NAMIE GR RAD TREY teh CREMATONYI2Z4EE tdtute}
CUR MELLON ol ~
voneressiona] Cemetery _sashineton, 5 .C 4
MEAVAL ae “fia f Pe
Poo PMN AT gg A A fe ONT MESS IO
By PNOERTAREE A SIGWRELCE [fi UNDERTARER'S -
: ia =a KEGINTH ATION / wt
MwoptSp AA etn bei GAWLER S SONS INC,
Aphis ct WE AVE BW. WASH. OF 200TR NUMBER
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ITE ME MACs 4 P00 ff ve. Aye Sah LL O of Sep ras __
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‘Date Issued: JULY 11, 1972 WOT VALID WITHOUT RAISED SEAL
ss
THIS IS TO CERTIFY THAT THE ABOVE IS A TRUE AND CORRECT REPRODUCTION
OF THE ORIGINAL CERTEFICATE FILED EN ORDER ve FHE VITAL RECORDS _¢
DIVISION OF THE DEPARTMENT OF HUMAN RESOURCES, DUSTRICT, PF COLUMBIA. Gy
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