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IC HE AL 415104 ). .+IC: OF COLUMBIA DEPATLI'T OI POLLIC HSALTH! CEnSTICATE OF DEATI 72 03405 HIKI Fu, Nu. NAMC OF DL45ED Lest DATI Month Jay Yra m. Hour ot ! DEATI! -721 h i.- M.Y . DATF OF JIRTH AGF: 1IH d1: Male White lust birthder) HownM. reyer rre van. 1395 7? id. T. wl. a' m wnn't Wishigton, D. C. Ist'at. R: ibtneF. (Where deened lieed. i inatitution, naidrnce be... NAMEOF11 NTATE i).c. ALN.O) admimen) 4936 - 3oth ilace, N.d. INSIDE CITY LIMIT bc Washinrton SPECIFY YES OH NO e n STREET ADMDRESS (1f rurol, pivc lor otiwn) per. 4936 - 30th I'lace, N.W. leck KIND OF BUSINESS CR 11. BIRTHPLACE TH CITIZEN OF WHAT COUNTIY Surng [rky red) INDU'STRY (State. ntyn cuuntry Dirertor U.S.A. F..I. 13 FATHNAME 13h. MOTHER'S MAHDEN NAMT. H.NAME OFSURVIVING SPOLSE Dickerson N. Hoover Annie I'. Scheitlin none be 15 }. 1.1HN17a INHORMANT RELATIONSHIP TO DECE ASED Ih. ADDRESS Streel C'ty Stale .neit Helen W. Sandy,. Cecretary, 4301 Conn. Ave., Nw, Wash., COY hen CAUS OI DEATH ne fur c.h.nd c). Intetval Hetween .ed. PAIATKANANR i Death IMMI DIATE CMTSE (n CerYusii <sed Fo.d.t.r. DET() .it a .cath Z .cnt DtETO (r) -alth PARI ! OIHEE FIGNIFKANT CONDTTKONS costlutang to death lyl t 19nAtrorsy?tr. Hf Yes. Were Fandngs unu CA YESOR NO :: af vio PHOKNH CONDITION FOR WHICH OPEHATION iaws O: DTEOF INJURY Month, Day. Year DESCRIRE HOW INJRY OCTRRL IEDICAL 211 IHky tl wok 21 Ih.'l f Nst'ky.SAs Hame.Farm, Furtory. NOLLYJUI JE CITY COUNTY STATE I certily thut (l) (this hcsilul) atlendud the decoased fron bat Iwok.s ind that death occurred SICNATURE DATE SICNED MEUHCA. NTAFT DRECTOR i 'hese n AHRESN Janes I.. l.uke :able : son- H' oitl. Stute) 5//72 Congressional Cemstery Washj ngton. ++ +++.W W.S.IsEr'h GAWLLR'S SONS INC. 25y INDERTAhEIA SIONAORE: UNDERTAKER'S AVt.. N. w. WASH. O.a 2006 REGINTRATION 1 NTMBER It wiih. Date Issued: JULY 11, 1972 NOT VALID WITHOUT RAISED SEAL THIS IS TO CERTIFY THAT THE ABOVE IS A TRUE AND CORRECT REPRODUCTION OF THE ORIGINAL CERTIFICATE FILFI) 1N ORDER WITH THE VITAL RECORDS : hardall ohn Crandall, Chief