HomeMy WebLinkAbout2978 ~ n-
1.t3 ~1~.~_'~.dl~ _
• r n e. - rrwT~ ~ro~o ow MuiTa CERTIFICATE OF DEA1'H
cur~ts • YYRtAU OF YIT/1L lTATir1'1C~ iTATR FIL[ NO.
1.~.1 FLflBIDA
ord •Asn '
SI T NO. R A~ .
,prop~rly 1. K1C~ OI O[Aril GOai NO. 2. YlWLL 11[M~tMC~(MS.v4w~.fNrr. 1lr.rirrr.: l.vd~.u+11~+~.:wi..)
~a~eui~d WUNTY a. STATE 0. COUMt'Y
•nd •111
b• p1~e~Q .
!n p~~- D. CIT/.7'OWN.OR LOCATpN IS ~LACE OF OfATM t. CITY. TOWN.OR lOG1TqM r. IS RE310EKCE
¦~p~nt IIISIOE CITY UMITSI !MSIOE CITY LI 1
rii.. Ft. P~B~CR resp MoC] Pt. PfeXCe res Mn
NAME f9F (If tMf (w ~apkd, /wt ~drsst alfrsMl I. STkEE7 ADOIIE55
INSTITUTION Rt • Z/ ~OX 1~ O
J Nwi1~ OF tYr~t Ni/Ide Liut 4A7E Mawtl DaI Ysn
VIVIENNE O. SULLIVAI+I ~?~+?ebruary 6, 1965
S. S£X 6. COIOR C~R RACE MR11RtED ~ NEVER MARRIED ~~III7H 9. A6E (4 rsv~ U~F~t ZI MlS.
r~ t 1A !vt bittA/~t1 XwW D~r Awn Mis.
M r 1 t• F W IM1001pED ? DIVORCED v~r t. • 1~ 171 ~
p 1 a 1 n 1~ ~a. ~SUAL OtCUiAT70N (OMs 4tw1 eJpork /oMS 1~. KMD OF ~iJSiNF_55 OR i~DUSTRY I1. ltRTM?UQ (~~ts w/oni/w cor~!?/) 1. G~172E1~ OI M~MT COIiNT~Yt
• i t A p~ r- Irrhy w~af oJ rakt~ l~Je, usn !J rKfrd)
go s ife O~m hane Oak Park Illi.noia USA
bl~ak lnic ~3. fATNER'4 NAME 11. MOTMER'S MAiOEN I/AME
o~
U trp~~rit~r Walter G. Olsen Pauline Ioae
~ t5. 1MAS DECEASEO EVEN ~!1 U. S. AlIMEO PDIICES~ 16- SOCI~L SECU11~tY NO. 17. MI • N~NA'PYH
~ ( Yw. r. rr wkr~wl l!1 w~. ~r w r rY~ +i/ ~wwr>
W NO .lrirus
v~~mfeal I!. CAIMr 1I KI1T11 (atn 1~l/ ows eswr~ oa~ (a).~ Irrt~ERE7Y ~/ETyrEEli
~ PAIIT 1. OE117M wA3 CAUSEO ~
dfr~otor ~MMEOIATF CAU3E n: C1C1°'7 ~dl. l}I'O~N?"11I1~,
~ su~t f11• ~ -
O te• e~r- ~
N tltic~t• C~~~,r~A~ D)
C7 •!t6 tA• r,u~ ~ ~ ~ -
1 o e a 1 ~bore
~ ~~gis~rar ~ DUE TO (e? _
y 1 L 010 72 ~ I SIfiM1ilCAlfi COMOITIOIfS ODK~fN1TM14 T6 OUT11 !UT NOT RE6aTE6 T9 TMF fERY1tNl pSEASf COlq1TqM GIYFJI M~MT 1(~) . WAS AUTOKY
. ~ YOa1'• •C- ~ /ERFQRMEDT
y.~ t~T dswtd ~
YES NO ?
a 6~ b~fols jpp_ pESLRi~E HOri iNJURY OCCURRED. (Elt(tr ftattirt oJhfuty iw P~ff !Ot Pafl 110JIfnw !eJ
¦akio~ •ny ~ ACGIDEFT SUICIDE MpMICIOE
~ Q~~po~i- tJ l] ? ?
tioa of ~ TIME OF Horr MontA, Dsy, Ycn
bodr. ~ ~WURY w~. .
~ y. ~t.
~ -
~ 20/. IrUURYOCCURRED~ .~PL/1 0/ tM.IURY (t. iw or dwul Aorn[, 20/. CITY. TOWM.OR 1OC11Tq11 COUMTY 57ATE
MIM14 AT ~~or wM~E~ ••••1t•~•.I~~+~t. k•ta. o~tc: ar~., sa.1
WORK AT 1YqRR~ ~ .J
. i -
21. I~tt~ndad tl~da~~~Nfio7n~.._ ' ' to •nd lut s~w h,m •lir~ on
t ~ ,'~..v_.C~-_~
i De~th ocour ~~t ~ m on the d~t~ ~tst~d ~boro; ~nd to ths boat a/ m~ knowl~d/s, /rom ths uu~p ~t~t~d~
~ lll lLS~• Ty~ . J~t J•r ~ r,(~tp},~offU'~') 22D. AODRESS 22t. DATESIGMfD
1 •rs tu D• x , _ _
cosplete ~ r~ CpY'O:lel' n- - r 2~..~ ~C
•eeuTate. ~ ~u ~ ~ ~T r v ~ ` ~ MEOFCEMETERYORCRfMATORY 23/. LOCATqM(Cit~,tv~eN.OttouAl~) (3tots)
B~iY'~'~ ~~2-9-65 ..Pierce Cemetexy Ft.Pi.erc~ FioriaA ~
V. 9. ~7 812 24. FUt1ERAL OIRE Op S SIGNAJURE a ~p q~ 5~ q~y,~ 25- DATE RECD. 6Y LOCA~ REG. 26• REGISTAAR'S 51GNATUR[
S .~•,7~1~I\'s~ .l411 S~•
&e~.1964 ' ~ r v
~
$~o~ ~~2 5 ~5
i _
L