Loading...
HomeMy WebLinkAbout0741 . . r.~~wi~~~~~~rrrr~i - ~ ~ . t~~2tt e~It~t ~ ~P ~~ttE2tf ` • . ~ ~ it . ~ ~ T~?. e.- rr~Ya ~oa~o or Nw~~ CERTIF'1CATE O~'' DF14TH sor~a • ¦UR[AU O~ YITAL RAYIfTiC~ lfATr F1Lt NO, ~~s~~ lLO$IDA ( erd •h+n ~ ~ M . p r o p~ r 1 r t KAQ~ M KATi1 G04t ' NO. 11WA~ ~M~MCR l 1~r~w~ ~rwnr 1.?~ I! i..ww... ~ RoNwr. Ws~.Mr.w+~.) •a~eut~d ~«TM t STRT[ d. COVMTY :.d ~l 1'3] ~a J~ach ~l or i .ia F`,~ ) ~n l3s~ach ~i.~.e i. y~r- e tirv. rowu, o~ ~ocszaN t. 1! ?LAC[ M O[ATM t. CITY. TOWM.OR iDCATqM t. IS RESlp~11C( ¦1Af11~ I?13i0[ C~'/ LiMIT3/ IN51 1?Y LIMIYSt r~i.. t,~ke ',:~~rth res Mo .in ~t f'd' ~ u~,~ch ,n~ ~ ~uME 0~ ~!J wt is W~If~t, /ire Nretl Nhwi t. ST11[E7' ADM~ESS ?KfSMTAL OII nrst~ruTa« ~r~~ 3.tJ .\vlnue >>~tth 3Pt0 ':.~.~h ~ ~t ~h ..oacl • ~ w?Ii1s M liM~t A/MiW Lrr ~ at1 J4fw+sf a~ Y'ta France~ 3. :t ~ck,~•et 1 o°u~TH Ju' 3t , t~3G~, SiK r GD~flll OM k11CE ~ MA11111Eb Q NL1KR MAlllll[D MTE OF ~IRTM 9 AG[ 1/~ KYI i~ LMO[~ f vW U~OIII H MS. • r ~ e. FCmd 1~ ~1 h i t e • rnooM[o avowccn P'eF . 1 4~~ ~~~1 x..w aq. w«.n w:.. pl alnl ~ IO~~ ilSUAL OCLU?ATIDM (Obt ki~~/rN~ AI~f K1Np0i WSIIIE'~OII'INDUSTIIY li. ~~rtrr~rti~ (su~re e. ~bnys sw~rr~) 1 GITRiN OF ~Mt C01J~R~tt c n p• twt,y wwr y w.tr,a ah. a~tn f/ rN~rN? Aousewi fr Own-Ho n~ (1 1 i n~~i~ C.;..1. , ?l.ct 1wt 1. FATME1t's raME 1? ~rOriKll's r11~ar MAMC or ~rr••~~c•r Ch•.ir' ^3 ~ch~ni ~3t ' ~ithcr ne ~1clCerna 1. M~S 0[CE~'3~D EKR IN tl i, AlIMRO IWI~iSt li SDCtA~ tul11TY M0. 17 IM • N~M~ (Y~. wr, r ~drwl U! M~. rr w~ p IMn ? iw~~) ~ C. !y• ~i,~ne None 36)O a:~ h:n Lon .t< -~.~.C..:. I~ a. /~n~r~l ewW~s N Kw~ (~e~+*w ww erwr M? lw+ at (el.~ ~ , tart[KViu, a~tMCtH _A'_ e _ D.~ ~~,TM ~ir~ecor ?~~Y o[aTN w~~c~?u![o!r LZ__ - - / ~wr[DUtTit tAVlE . r ~ r~~t tll• - - - - - - , t\s e~r- .i ^ tifiert• C~. i~q1, p~ Tp (bl r i t ~ t A• ~v?k~ rw ?~+r - - i ~ e ~ 1 ~6Me ttiae ~ r~~ i ~ t r a r M~f4y t4r r~/~r• OUE TO (c1 ` , •ltala Ta ~ c~rK lyf. ~e~~ • a C- ?~T 11. 0'f1~11 Sit1r/1C4MT Q11f1~U1'Mi TO OL~1M ~ iKR ~[IA~[D 101M[ Od47[ COMpTpM G11tN M M/T 1(~) A4 KRfORM[Ot tYt d~~tA '.~5~ ~ YES? !q~ t~ttsto~n 7A~ ~ 7DA. OC~CRIYL MOM IMJU111r OCCUIIIIED (Elt1n fdt~i~ ~Jtwjr?/ iw Pvr t a P~ l~ ybew rt.) ~ i ~ Y ~ A[C~D[MT SIlit10[ lIOMKI~E f ils~~~i- ? i ti~r •f ~ TfrE bi Nw~ ANwN. Dp. Ys~ ?~d1• ~ IRJURY N. 1N. 20i. tNJ1JRY OGCi1MKp ~IIM. [ dF NWJ/111 M M~t Ma~t. ~D/ tRT. tOiMM. Ofl LOCATIOM tOUKri STATE 1M01lK A7 Q MOT~~Li ~ ~.1~?1. IbaM. t~ 01~.. Kc.) !i .(~fi~n~hd tM f~ew~nf troa~ ~ 7 . to +j y s 1,~ ~ 9~ ~•nd lut pr ~~Ji~~ an DNtA ooou?rr1 ~t t O~ O w~ on tA+~ ItN rt~t«l ~iw~: ~rtd ta fM Owf M es~ twoMl~A/~. 1?om t wu~ ~t~tK. t sl i i t~a• y~ M~y,~.,~ ( ~r M tY1r) ~ !~1 ADOntsS / l y-- , 7rc. anTE •tf ZO f ~ O~q~~t• 1k ~ K„/ ~ .Z ~ •e ir!'~t~. 23~, MAAI. t~trMtlOw. LM OATL ' . N~Mt O~' CRME'f~sr at C11[M~'1'OMr !9/. LOCATIOlt fC~h. NM. M e~~M1) ( 1 IILIIOIrK t9 ~ 8,'~ ' Huri~r r ~ ~alm Dea?ch Me~. P:.~rk P~1 Beach County - r' la , r. a./ e i ~ tt ~ ~ooRC~ a t i na L C h =s. arc acc. ~r wc.i ecs. s~mu?~s s~au? ~ a...itss Bo ton Dch. , Fla~. I H'~REBY CEATIFY ~iE AHQR T~Q B8 A 7RU8 ANI~CORRF.CT COP'Y OF THS R~GISTRlIR,'S RECOFtT,1 QN ~'IIE IN THIS Cg'FICE (~iot tali~d ut~l~~s th~ a~al ot th~ Pa]~t ~eto~T l~alth ])sp~rt~snt i.e a!'fi~osdy ~4'~. ~ t tw CEE~TIFI~ ~4P'i ' ~ ~ r ~ ' . . ~ •t ~ - . Loaal ' r . . ~ ~ ~ j~et ~s 1965 ' i~ist Pa~ t ' - ` ' ~ r ~ . • j.'~ _ . _ . _ . ~ _ . . . ~ ~ . . ~ ~EsP~Q~A t . ~ ,~~d OK i Q~ ~ ~JCT S PM 3 ~ a3 ,r~ ~ ,~.3. . • ; •."71r.`.`ty/ . f'~ {r' ~`~Ol1P YYRK . Li ~ F~ptn M1 ` f. ~ S~. T?! W .J ' A i . . a~ X~~U Bvn