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HomeMy WebLinkAbout1207 . ~ ~ 9 f re~. ~'TAT[ ~ow~o or Mrw~.r~ CEF:TiFICATE OF DEATH ' t.,~1 ~i.i•. IL ~ • euwuu or v~~ rrwr~r~np trwr~ ri~c Mo. r•°- FLORIDA •r~ .A~n dl H . p[difT11AR•S MO. ~r~p~rlT a e u t~ d 1. ?IACi N~tATM GOD [ NO. 2. YlYAI A[NO[IIR[ ( /~r.r1 t..d lJ.+Mw~.+~ Rc.l.+~. 6~~ ~:~:r: ~111 ~«TY t. ST~TE D. tOUMTY ~l~t~d ~~t- D. CITY. TO*M. O~ LOCATlOM IS ?UCE Of OfA N t. CITY, TOWk, OI! LOCATqM f. IS REYIOEIICE •aN~t INSiOE CITY IiM~T51 IMIOE GTY U0111 fll~• YES Iq? YES? M0~ I, NAME OF y~( {~q aydn~) ~ 4ENGTN Oi 57REET ADDRESS MOSIIT~L OI! STA~ IN Ib G'M A?AIIMT fMSTITUTqN YES ? fq M 3 MA~1t N Fb~t Ni/rk Lru 1 DATE Ns~t1 Dq Yto ~ce~wsi~ a (TY1Y~ M D~~) DEATH ~ S. SEX ~ COLOR 01l RACE ~ MA~IIIED ? NEVEII MAR111E0 ? e~TE Of •IRTN 9 AGE (Iw /tP~ r~w ~ YW WOER ~I MS !ad ~irtNa/) M..W ON¦ Bw.~ Y1.. r e 1 t• ~i ~ w100MED D1vOxCED ~ - '1~1~11 ~q~. ~UALOCCU~~TKkI(04eti~io/~akl~wt KIMDOFW51ME550111NDUSTRY i111TH/UCE1~aPtOrfOrtl/t1[oltstvr) 12 Cf?t3l11 rfMT00UM'IR~f~t •itA psr- I~rhy ~eeM eJr~rki~h~e, eKw tJrdird) ear~~t TF,pCHER PUB I /1a0k 111k ~3. FATliE~~S RAME 1~ MOTMEII~S MAIpEM M4~tE O~ t~r~~r~ta~ WILLIAM J BLAINE MA h' 1. w~3 DECfASED EVER IM U S. AlIMfO ip11CE5~ 16 SOCIA~ SFCUPiTY NO. 17 IM/O~IAIIT 0 6101iATYR[ Sh rle K. Toth 1 rw. r rwiw~../ I rl r'+. hwr ru ir fNw ~1 ~vwr~ y No ~ _ ~u,~.. - - Sun~ral 1• CliYfi N~dATM (6~ s+~J1 n~ tswr Dsr l~we J~+r (~f. I~i~. oe! iRTERV~I ~ETMEEN r~~ t O ~ ~ANT i. pEATM IMAS CAUSf D!Y~ WISE7 AMO DEATII au~t f~1• ~y~+[o~~h uust _~tlt..4~_.~~ZS?$~IIQ118 _I.1.1GkQII1~8 _ - - - - - - tdY l~fde~ ts• e~~- tiflc+ts {.~u~,~~~r. •itti th• rAic~ u vVE To (b) - /~e't r ~ te ~ - - ~ - - - - - ~ ~ - - - - - ~ - - - - - - - 1 9 e a 1 ~Oa~a r~ru (~1• r~~lrtrar (;i~~~ ~ 1~ q;E 70 (t)~-- ~ - - . _ •1~Aln 71 - IOY~ f- /Al1T 11 OTIQ $If•MIFIGo/T C011p'ld6 COKTIN~IJTK TO DE~iN ~JT Mpi REUTFD TO TME 'El1Y!!qAL q5ElE5E COMOITqM G~VEM IN ~MT 1(tlJ WAS AUTOPST ` hE RiOR Y E D7 tor d~at~ V •r b~fo~• - _ YES? NQ ~ 2(1D DESCRisE HOW !M1uRY CKCURRED tF.'ntrr natrrr o/inj4ry ta PUrI IOt Pas! ll~lylitrw l;.) .at~¦~ any ~ ACC~DFMT w~ao¢ ~+oM,cn_,E alrPO.t- O O C] ~ t f ~ ¦ o t - - - - ' - • • . ID[ TIME Oi Honr ~(~7~. lh~, Y~v ~~dy. ~ iwu~Y a. u. ' 'o v ~w. W _9 ~ , ~ 2(1/ 11WUR~OGCURIIEO 2Dt ?LACE Of IMJURY (t. 0., iw m a~out Romt, 2DJ CiTY. TOWN. OR IOCATK~M ~ CpUNTY : " STATE WN4E AT ~ tipT WHILE ~ Ja++w, /~rtor~, ~1r~r7, o~'iu ~'6p . tfr.i _ - _ wa+~x ~T woaK - ~ = 21 . ! ~tt~nd~d th~ d~c~~ad /rom ~=2g_~~•.b,(y - . ro . _~-2.~s1~ •nd l~it~a~c~ •tirs oh , ~ hiq~ . ' -~--T- D~~th xc~~r~d ~t ~~_~~...~.~T____.__. _ m on th~ d~fs sNf~d abore; ~nd fo ths 6qt 0/,n9r!lnoMHdri, frd~fi,['h~e c~u~ra st~f~d ~l l it~~• ~ Nil1ATYR[ s~• b• ~~P~« or llllti 21D I.DDRESS . ZZe. DATE SICqEC es~'ltt• ! •CCY~~~~. ~ KIR14L, (~MATIqI j~p D4TE Z]t NAME OF CEMETE aV OR CREM~TORY 23~ ~p~~7pN ~~V~~ ap~w, M~pyNty~ ~~~t) REMOY4 (5D«~/~l P.s.#eis Zi ru~c~~~ i cc a~ 3sw~~'r~ :~S N° PI~tCE ~.~DA , ~ ~ ZS GAfE RECD. BY IOC~I REG 25 REGISTIIAR S 51G~1ATURE t~~. IQ66 F'T. P?ERCEa FLA. ~-4-64 Anna iwa--Ber~~aorr,~ d^r. l.i~?ereb~y cerf'rfy this b he a true and correct copy of the Loca! . ' Rt-~+i5~r3r's wecnrd o,~ f~'e iri the St. Lu_ie County H^~Ith Depart- ttl~r.t 8t Fc't Fie::e, Fi~rida. ~ ~ . ~ ~'1LED aND REC ~ ~K ' (~'VarRirK7~ ivot va~id un`^ss raised se31 c{ ' ~ St. k~c~e !~1 " Count; t;e~ th ~`~;~::rt~r.en* is :~fi; . . '`~~~~~~5~ , ' N. D. P,hl!!~.P,. t:1. +7. ~c F~l,,ry~-'~' Jtl~ • , ~ ~ " County Ne3'tn Officer & La_~I Regis'rar v ~ ~~t ' ~ ~ ~ ~ ' ~OGER PGi~i RAS, CLERK ~ ~-~5"- ~k ~o~.tt ~A.i ~..~t7n~a.. ST. l.UC1E COt1N1Y. _ De4r Dep~ry Local Reqistrar ~ r ~~.pa~Da ~ ~ , ~~:~~,~~,fl ~