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HomeMy WebLinkAbout1246 . ~ n- sT,~T~ oor.no x~,.~_n~ C."-=: i i tF!Ci^-~~'~ Gf' U~EATH ~ 1 : _ F3UetCAiJ OF V17.~.. 'ATI&'TTtb' 6-..-.:~ FILE NO.- ~ FLORID~ r ' kir,~4 ~:0. _ i:EGISTRAR~S ~ ! `7 r~v r_ rr:--_'___.'____~=_'s..=-_:_~.-cr_r'r_r ' _ _ _ 'c_ ~..c'-_' exrtute.t i. ;~Li.Ci: OF ~EATH ;CODE RO. ---USiJAL RESiD:..:C~ fl~h,~redunc.•.t;nr1 ir~r.iu~_::-r,~r<,i;.• , wr,. ril l t. CiJUtiSY ' L -t ~7Ai~ , , b. COJ\TY . ,"~f yc~lsc.~~i ~ .~1.t. _~~.ZC~~ _ ' CJ:7~i~ ~:z ~.Y~~Q~ J~__-S'`~.,i_.:Zc': ln r•r- CfiY or.ct.;~ c..r~~.•:te 1:m7:~. ~sr::e I:i xdL; c. lE!aGiH C'r - - ~ C. CITY il! wubSa rozyvr.• llm~u. wriu CC::ALi •eue~~t OR ~ SSAYttoa,:~v:+~•i~: GR tiie. 'OWN ~'~i• ~iL'T'C8 tF$~'S ~ TOW4 i~i. +~f'T'Cd ~ d. YULL t~ ~~•l: il: e5[ le 1wl.~IS~I Ot 1:3I::b:IJ'.. ~l~a ~:reri ?.l.::c.z ~f l..e~1:m) d. dc~T iSt rvr.1. rir• y-.ay:lonl ~ HOSr'~Tnl CR ~ ADDR.35 ` . 1!vST;iGS:ON ~ l,i ~'}'1 ,c~,~ ~ ------.~I~, 1.~_ - - ------~lu ~.__~.;,1.._~ - - - . - L _ _ _ . ' _ - ' . ~ 3. \i:"/.E. Or s(FircS) b_ (~SiQd:t; a iLait) i 4. DAiE {3ir,ntL) {D;3') (1'.::~r) CGC~AStD ~r i'L'.+.,r P,;nt. J_Z.~_.~,"_:~'_~rl:s.a Y~.'":j:~._-- --~'-i.~'.'t'h__~~_.~ GLA7H ~.C v_t~ ~__?-'r'..?1_ S~S~X ~ 6. CO.QR OR RACE 7 i. ~5?.~E`v, heYF MA.cwIED S. DA?k OF &!R'H 4 A5c ; se~rt ~r uw<n ~ s~ r ~•~i n n ~ y~; ~ V+ ~'vYf~D, UIVGRCED ~g;,«;ry) ; Q ~ tuc otrwi.~i 3f.r.ct~ L~c~ 1 ~.r~ , ~l:.z a ~ t e -.G',v``^^-+-t~ 1 v~',+1~. 4t~' i _?;t'I'i SC~ _--a.'~_i.;''i--1 ~~_-'~r U ' ~ i . .a 1 r, I y - - - - - ~,,et- .=~~~n.. GCCU:ATiON~.Gi.o ttr:d o( ~~r1i{~b. KItrD O~ BUSItieSS OA lN- f:L kTriFLACE ~HUU ar (or~tio munen) ~ 12. CiTf«N GF W4AT ~~,r:;Jf r.-.... c• o~~rl~:,c ~~r~. erw S: rvt~red} D'JST$Y ~ , COy?:.TRT7 ' _:c,~~.s~wifa ~ + ..e~; ~ Varrror,t v~y t~n.. - r ,,ort: ~r " IS• FA;HER'S f7AM6 1S. F!OTHER'S M/~tGEN KA?.f@ t~~orrttt~r (..C~~(^JG~ ~~~':Zt~ I ^ 1~ P _~Xr~..~.~ t5. WAS cECeASE~J bVER IN V. S.ADl.~Fu F6RGF57 1G. SO~i~L SECURffT ! 17. lNrORMANT'S St6NATURB ~{j;S0:1 Clark lYa]. I.J. OT W~,l.^.ir~nl {~It ~u. st~~• •.r or d.v. ot .~n:~•~ ; NO. ( - y ~ ~nr_...~'1?_~~(1'' ~R A~~~~ss c~ k'.~ "'1 ~~,-n; 5 CA~~E GF Ce/~7rli MEDiCAL. CEtcTlF;CATION ;~~iYIAYAL uerhrcv rrctor : rt o~,~ ~ne caumc~l DISEI.SE C.^, CO'i:.3T:Qti _ . \ ONSET pH0 flcwt-N t file D :~,e.o',la). ~.b).~ ~IRiGTLYLEAO~tiG :v GEAi~i•~b~ ~p-'r'n ''.r~S~'~-vsrt.~~li_~n. .t tL~ cet- nr,~1 (c~ + - ~ t t,'t ~ c e i nNTECEDEN; CAUSES •1 ch. tTa •~±}.it dGr~ •'~L mear.i JUC TO (b) - - - - - - i 1 4 c n 1 • c r,': o~ dy:n•:y.liJrL~u Nndit~;Ti. it cnV. ~ ~:~7 . • a hr,•. !~~;xrr,,r:ar to IF.a cG~~.~ w,:.nr :c1 . - f . r,•qisCrsr .s her i rt_. It K:rsna ixp ti~~ anderlynn~ :~uee i- eC I ~ •lt-^ir~ . t.. _~~ec inJu or'~„__ DUk TO (t} T- . . . h~,;-s etf ~~I c~,m'r~~~~"~•~n ~h~~~;IL OTHEflSlGNIFICAN; CCti"vST~vP:$ ~ ~ rntt. ralscd S!.:tt:. ~ Cer ' Conr'iCiona eort:ri,u.:i~y, :o N:s ~.ath ln:i xaL ur T,t!cro ~ y ra~n.~~fo th< du~.:...; ^ditioi CS•19t~1~~[I!1~:. fy ' • ani~i.g nr,T 74s. DAIE OF OPE~A•;lSb. i.lAJOA flkDtNCGS OF C?i~ITiON f .•/f1,ITOPST? ~ Cisrost- TION~ . . ~1~' t;on of . i vcs LJ r,o? D,; ~p. --,;nz.:;y> i3t:<:t~i j 2Ib. PUCE O~ lNJU'wY c..s.. in or ak.ct ' 21c. (CI7Y OR TOWt~ (COUtiTY~ (.;A7E) :IS. wce~~[r~r om~. t.rm. h~iory. ~~raet. c.2a 0~.. Fa) ~ 3: rw'~1. ~4N HIIIi.ALt SVlCICE ~ ~ __2:9:iClII~ ~ _.v~_' 21d. ~l!.!c i>So.;o) ~:~.s) ~Y~~r: tt~ow~ .~e. 1NJURY ~CCUxR~D j2?~HOW Di6 INJU0.Y OCCU&7 bF ~ r: i~c~r KorwN+ts I IN;UhY ~ ( ~oq• ? aiwo~K ? 1'r,rr~by tcr:i/y ti~n.t 1 c:tcnded .'~e dcccased fr'~rr.i'•:~., 19~, !o._._ la tF.ct 1::uC sa;: +1ec~r„~d ; ~ fr, l ~ O 7< < ~ fu^L•'fiCS R Oi : C 4~1~P. tl r F Ai~ iceas •?ir~. ,~~1-~.~,.`:-. 1:=~tn~~ )_~,~r.~.. ncc~:;rcd a: ~ ~r..,from 2F.e r.d ~ F, c.~^ r,.~;,rr. nre to Ue ;ja: ~jG:VATUtZE. ~ ~ (DeYrue oz Yic:c)~!%ib. A~C~SS ~:3c. Gi4TtSiG.`.eD tor;~lote ~ ~ i a c c•~ r R t v. ~ Y n'^ n i) r t"~ L,r r; 1'Y1 _ ~~i i~.~ ~ i ~ i_ e~,'~ f~~ c:. p I ~ tn' ~~.~_c_ 8 U~.°. 1.t L, GkcMA-~.<C. DATE ` 1 !:4c. NI.l.iE GF CEMEiE2Y OR CeEMATO+~Y ~24d, Lt`.+CATION (CiU', V+vcn, ar cav~ty) (SCete} iIGN, RihSOVAI t_~mttt) i 7 ~ ' r~ ~_.~.n.. fy- l C' C~~:zis~;'~'-~r.`r-r'~~~..y I ~~'•L:•_T1b1'~i~ ~Ytt~i'~:%i:l~+ - _ 4=:a~.-...:1.----.--` f~~ . .~A;r ?6C D'eY LC:.a~,;,EGISTR~F S Si6\ATJ~c +5. FJN~2AL DIRcG~OR'S SIvkATURE AGDFfi55 RE~.i Y . y~z~JO .~~r„~~t ~ ' ,J ~ i`• r~t~i-_i"c.w.'r_~--'J ac...~~a._fis.my~.__3~~.y ~ _ts.~.~." i~ ~y_ r_F.'~ k~ 4' ' ~'j„ ~,~~.~y t'~ n ~ ir'~ Jz-~ . I ) J ( • heretiy certify this to ba a tr~e and c~rracr copy afi ;he L~c3 ' R,tg i~t~r~ r~card on fi4e ~n th~ sr. co~nr•~ N~,~rn o~~~~r- FIL~~ ANG R~CORDED rrt~n't et FcSr~ Pierce, florida. ! R~ ' ~ ~ ~ . ~ ~:~~c~a~ R~t - ,(Warning~ .f~:ot~trd;fd un'e~s ra;s~d ~e.. _ t;~e St. Lu::e ' ~ County-f',eaith Der:.rs ;~.r.nt ;s ~rii~ad.) ~ '6~ DEC 10 AM I i: y6 ' ~ ~ N. D. h111.1~2, lf~. ~ ~ ~ ' i a ' , , , ; ; ` ' ~ Caunty F;ta;th Uif~cer & tat; i ~egistrar , ROG~,. . ~ - CLEI~K ~ ~ 5~~.~LUl'.lE CQUNTY. paf6 Deputy ! c~cal Rtgistrar d F~.O R I D~ BORlt1JJ _ 4