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MISSISSIPPI STATE DEPARTMENT OF HEALTH VITAL RECORDS
1 4?.,?* iT/&
Bureau of the Canaue
S-(0iN C;.r iiCS?llALPr?Q^'
* m
;5 .1343
department OF commerce STANDARD CERTIFICATE OF DEATH
STATE OF MISSISSIPPI
---------Corpor.U Llmtur
?? Mural -----------P^cirm_____
*<?i. nu n*. 1(WT?6 ?----
lssld?
1. PLACE OF OEATM?
County____limrjU.Qn______________T imnl 
Hn?plt?it	HQ3p__j.	>?U.L. and Nufflbtr_? r-.-: -?	_
Length of Stay Before Death, (a) In Hospital. iOi.daya^.. ? (b) In thla Community ? ? ? ??>	?	?
z residence before death?	?
ili33is3lp?i
County
Hanoock $'?;r Bay St. Lou 1^1..'
3. (a) FULL NAME
Lira# Ann a Pcrr*.
3. (b) If veteran, name war....
3 <c) Social Security No.______________________
4. S'
IS. Golor.or Race
unite
? (b) Nam* of huaband or wife...
6 (a) Single, wldowfd, ma/rle^,
married
divorced..
6 (c) Ago of huaband or wife if
Eaile Pjrro.				7 S y.?.
				1880
		(Month)	(Day)	(Tear)
1. AGE: Yean	Months	Day*	If feae than one day	
?a -	-- ----		I**.	mln.
t. Birthplace
Nsw Orlaans. La.
(City, towg or county^^^tate or foreign country)
10.	Uaual occupation
11.	industry or buelnei
Ovm Hoh?
Other oonditiona
(Include precnancy within 3 months of death)
12. Name
Jcffarson. SauJcnauu,
iJ	J?ffcr3on	Pariah,	La.
j 13. Birthplace^
(City, town, or county) (Stale or foreign country)
W fl4. Malden namo LAaai.s_3.?.u?LLfiiL._
Jsffsrson Pariah. La.
oll5. Birthplace------------
2 I	(City.	town,	or county) (State or foreign country)
;s te. !sfWRMBS.s	Parro. .......
<b) Addrvu	Louis	,_____MiS_S_.______
it	_______________(b, o.?._Zz24_-48 _
(Burial, cremation, or removal)	(Month)	(Day)	(Year)
Bay St.Louia, lliaa.
(c) Place-------------?~?f--------------------
.-^.-Ephov Undertaking Cfc.
It (a) Signature, funeral dlrectbF^.~~~.?i???--????....
<b> BjX_4^L?uj^_liLaa.._______________________
1? (a) f/^J^LcV-S
____(Dale received local reylatrxr)
L>cr
Fersifft Born
Hsw Lew ?n U. ft. T
MEDICAL^-CKRTIFICATION
20.	Date of de^h: J^onth-..^^*^^!^_________?<*y <r-/
y??f	hour...
21.	jh^terp^y certify that I at^
M._________it:
ttSat I (ast'saw h^l^'alive on. .	^^2.f
and that death occurred on the date and hvdr >UU<I afce??.
OURAT/DN
Immediate, cause of death_/7
ita, cause of doath_/^CX^3?
'ter*.
MAJOR FINDINGS: tD A + * *\B *
Of operation	_
<-A
Of autepay
PHYSICIAN
Und?H?M
the c?vm to which Math a h e u I d be
charged eta.
tlatlcaUy.
22. If death waa due to external causes, fill In the following:
(a)	Aocident, suicide, or homicide (specify)............?--------?
(b)	Date of occurrence______________________?....??------------------
(e) Where did injury occur?.._________________
(City or town) (County) (State) (d) Did Injury occur In or about home, on farm. In Indurtrial
place, In public place?..
(Specify type of place)
THIS IS TO CERTIFY THAT THE ABOVE tS A TRUE ANO CORRECT COPY OF THE CERTIFICATE ON FILE IN THiS 0FF)CE
"?A*y>y!>+0n
F. E. Thompson. Jr.. M.D.. M.P H STATE HEALTH OFFICER
September 30, 1993
Nita Cox Gunter STATE REGISTRAR
WARNING:
* REFROOUCTON Of THK OOCUMENT RENOERS n VDO ANO MMX DO NOT ACCEPT UNLESS EMBOSSED SEAL OF T>C USSSSPFI SttTE BOARO OF HEALTH IS PRESENT IT IS LLEOAL TO ALTER OR COUtTEDFBT TMS DOCUMENT