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HomeMy WebLinkAbout2994 ~ ~ ? yZ ~ t•sv F« il,,oo 14~?~ FILEO AND RECORDE~ ' ~T. ~UC~E COUNTY. FLA,'~ ~ CONNECTICUT STATE DEPARTMENT OF HEAL~~'~?~ v~R1F1ED Bttna• of V:td Statistiea # ce~ea c~,? ~ n~,?~ R~a '66 ~!U!' I 6 PM 2: 2 S i. F.u o~ a~~a .........~BBZ.~i~ATI~.S?.IE~.» i~........ 2. Prioaq urs~ of d~atL .....~iAMD~'r..~ I! 3Mta troa ~iokat aus~ ~este lll maaas od wtare of lslar~ (t) w6etAer ~ideatai oa i~~7~~~ • oaC~f~Cl~~d...~.~~~,ya 4. S~eoaaae~ or cootdb~toq ........~t~?.T.'~~.~..~~R~~R D~ to ~rt~riosc2~s;ot3a H~srt ~eas~ " . a. Dwrattoa , ia~. ~ R•sarlrs r pj •~'Y~d. ~~.~7•Oa.61~JC~~ was as wbove~atat~ last i[tness, sad t6at the c+?we of dswth \ Sisaat~» ~ ~d~1C~l,.~i~11~0~r• ...~Y~~d., ~ . : c,~c~'~.~`Gii~e ~..rsa:- ~ . Dat~ 6~g~~ 1~~ Addr~aa ..r~...~~~1...~t~t~.. ~~~.t~a...~A~1i ~ s Uadertaker's CertiGcate 1. Fall aa~• of d~e~asNi ....~..~i2'~21..~1~l - Z. Plan oE ~+?th--Tow~ . ~A~~ . No . Strw Ward ~ . . . ~Q ~Q~. , It destb oesare~d iu ho~piW or tastitotios d~itCi~aaie iwte~d~ot ~tie~t ~d nan4er. ~ 3. N~mb~r of familia ia LesN 4. RMiaeaea at tim~ of ~atk ....,~~..~1'A~Ti~..~GQf.jl~..: if3l'~@~...~.~Ar~A ..1.~~~ To~l 84t~ Oe" Coantr7 t S. ~Ot~pttio~ 6. Co~diti~ (atab ~rL~tL~t siasb. asarri~d. i~oe~ or w~idowai) .....~~s~•........» 7. If wif~ or widow. siry aam~ of hubui .......J4i~t3,rii..$~OJ~i 8. DRb of d~atL-~us .........~7Vf~..........» moat` ...........~1~..................., da~ 9. Dab of birt6-~~ar ..............2~s........................................ moat6 ...........SQ~................., da~ t0. As~ ia ~ear~ ~Q...................................»...... moaths da~s ll. IZ. Color ...........~t~.tiR.......................»»...........»... ls. BirtLpLe~--Tow~ .......~a~.OL'~?l~f 3tab or Coa~tyry ...~.Ol'.i?EtC~.~.L,`,~i~..........»..»..... 14. FartL~r's sam~ ia fall ...........~~~.ag:~r,~.~,~+1~.~ 15. Fat~r a bietbplae~-Towa Stat~ or Coaatrf ......Gal~...........».»..»..»..... 16. MotLer's aid~a nsm~ . .......~..~A~» l7. Motbie's birthplae~---Tana .........~1..~R~'~ Stat~ or Cotiatry ........~Y..~Q~G»............»....»., ls. Plw oE b~rial .........~~.Cs~r...se~~l~» C~mebr~ l8. N~m~ oE iaforma~t .....~'~..~..~~~A,T.~?~~R... Addna~ ..~.RA..~i.~~ ~11~?.»...... m. w.. bod~ ~abalai .......~:~5 o~ mbatmer ...!T•,, War1'~n .Gt~tfith j.ie.a.w I~ia Sis~+?h» of Us~rtai~ .....~T..~..~t..~~p.......... Addr~sa ..~...~s.~r11~~?..~T~fl.1?...~~l.. (os 13e~ss~ Eib~l~r) CES CA RECS SD R HD , J~. 9. 1966 I ~Barb.r. ''r ` . ~ io~i~`~~ ' ~ ~ ' ' ' ' : • . . I e~etif~ that eLis is a tr~~ tra,saript of t~ i~toswtioa on tL~ i~c' ~~ur~ ai :ei~or~ii. i~' tLis o~ie~. Att~.t~ e~, l,. ` .i ! ' ` • j r . ....~.w~~'» ..iw~~ : ?e~~ ~ ~Mf : Yitai 3taWtles i.• ~ `JJ.~~~ Dat~i ............'.1N~.14~.........1~ Te~ ef ~ya.:.:..~.,.n.~...:.;..~.:.»».........»................... ~ r y { i Fo~ o-v.a i~ t:-~~~ s~c NO'T G~OD Wl~ OF CERT~FYING OI~'~'iC~#. Qoo~~ _ _ _ 59~ . ~ 3 s~ - - ,