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HomeMy WebLinkAbout2088 ~-490Q'~ ',a. s~~•~•- ~TATt .o~~o or N~?cn~ CERTlFlCATE OF DEATH ~ ce.•s • ~VA~V pR V~µ, RATi~Y1C~ lTATt IIL[ NO. ''R•` FL08tDA ' ~ ' p?~p~rl~ a1RTN NO. R tT11A NO. •~~ert~~ 1. KAt[ ~I WfN COOt NO. MYAI ~[S1~[Nttl~Mw~wrlt~l lliw~.N: A~~I~.rW~~w.w? .~~i oow«Tr 81'OW~tl~d ~6-d~o a sT~n Florida ~ oa~T~ LuCfe L: $3ssN 1 n ~~f• tlTr. TOwN.OA IOCATqM t. IS K~lt Of Ot4TN t. dTr.10~11.0~ LBtATq11 t. 1S 11[S~D(NC[ ~'ort Lauderdate `~"~n' r~t.. ,r~ „o Fk Ptel'Ce ~s ,a f. 1ulMf OI (~I Mf /A ~N1r~1. f~t IbNf N~dr) STIU[T AOOA[ts I ~ TU1qM DQA Broward General Hos ital 1921 Fulton Drive ~ uwM~ o? I+Int /1fNMt LMf WT[ MMN D~I Yra ~ccu?sc~ cnr~ Samuel O. Celtfl o°u'~ July 5, 1966 ~ S. S(x i_ COlo11 O~ 11AC[ • 11MR1[O ~ NCK~ MA~O • OATE 0~ M11iN . AGE ( KM~ r uwoa ~ rw uwa+e N Ms. ?r r t t• a~?L~le ~ 1~~~p INt Mrq14) Nwr~ O~~ Mww MM. ~ ~ Janua 12 1913 , s w 1 r 10~. uw~l ottwATqM (IMe RI~I ywr! Mw IM. Rw0 oF N~SIRSSa1! 111011ST~Ir 11. M~Twtl1C[ (STde w/M~Iq awl?~) pnta ar ~ar?r oou~r~ r 1 t A P~ f~ 1t?IlN qNf YML1M AIM ~~/~fn . ~onducfior Ratlroad Sateer Florida U. S. A. ~latk !11• 1 iATN[A"S 1U?M[ . MpTl1EA'f MAlO[N N~M[ ! er =r...~,~•• Samuel J. Catn Tlizabetb A3rere ~s. socu~ ucusnr Na. n. ~ s~~w~ wu~n. Il tl Ve ~ 261- 9-3282 Mrs Samuel O. Cain F ~da ~ - Fu n• r a 1 1~. tAYK N KATN (bl~k/ Ml/ Mt tMM M fhY r(t1. ~(e).~ urtc~v~t scrwct~ e? ~.or ?+~RT a~rN wns uusco ~r~ ACIlti9 ~.'OI'OD3 ~811~~C~8Y1C aacr uw ouT» . t, wwcou?TC c~ac tu .t t n. e..- ~ + s f C 1 e~ s• C~s1iN~u. i/ n/. q~ ro h~ 01 t ~ t rAid ~s~t ? ~y ; 1 o e• 1 ~r t~wt~il. ~ rralst~af w~N ~ : lfi+~I nrat f~M. OYE TO (t) j r o u r s p ~ f' ~ IMT N. OtKA SICN~K~IR Oi0M01T~01K GOMI~IM 10 aATM MR ~ ~[1~R~ !O 11R la1MYl OlifAf~ ~lplbll ilY~1 M fMT 1(V . NAS AUTOKY ! rtitro~twtor ; t~r e~~t! 3 cr D~t~r• ~ + t 1 w~ ~w~ Acc~D[NT SY~C~DE NOYICIGE 700. otstswt Now wiuer octv~~to. (is~e? ~r~?e M W~a~ b Art l~r Prr Il N k~~ i~.) - ai.P..1- ri ~ ~ . cien •t ~ ' led~. lOC. T~rt Os Hwr J1~pfl. Dq. Ynr ~ uuv~r 'o s••• W ~ 20/. pUURY OCCUMEO mt. KACE Oi INJVIIt (t. ~.,1~ ~r ~IINf w~t, mI- CITr, TOMN. O~ IOCATION ODYNTr ST~TE irNR[ AT ~ NOT MN~LE ~ J~?A. J~MI. ~f?tlf. ~~tt MI~.. Nt.) ^ 1NORK AT MqQK - V, 21- I~t rN~~wil/ww ~wd /~N.~r~ ~JwMA • tA urnl ~t . u~ en fA~ d~t~ at~f~d~Aw~; ~nd fe fM 6Mt vf m~ lnowl~dp. lrom fA~ e~ua~s ~f~t~d. ' All St~~~ . ~ Rt •r• to 1• ~aKKK~) m. ~~E~ ?2t. MTE5IGN[D ~ a«~~oTs~~L~•~• ( Medical Examiner Fort Lauderdale, Florida 5 July 1966 ~ _ 1 2~. pUUnOiI DATE Zk. NAME OF CCM[T[~Y O~ tREYATO~~ 23/. LOCATIOM (Gtf/. lM~D. M tN1atI1 (S7~ft1 ~ ~Il emova~'' I 1966 ~ F Pierce Florida v. a. ~ s i s t~. ~ u II ~ ' a? ca tn+r~~ocpK ~w/. ~sT ~s s~c~u? ec : l~r.li~i ~~~IG4 N ~ CERTIFIED COPY ; . ~ I hereby aertiiy the abore to be a trae and oorreat oopy of the Loaal } Registrar'e reaord on file in the Brorrard Couat~ Health Department at ~ Fort Lauderdale, Florids. ~ = ' •~E~~•`•~/`l ~ '~Iye~~ih~~. 0~ ~sl~d unlees raised seal of ths Brorard Caunty Health } - . { ~b~aqnt i• atfiz~d. ) . ~Z. ~ ~ r~ . / i ~ ~ . • ' ~S t ~ 'J ! . i r~ ti t'+ e O 4' % ~ ~ 'j~ .~s d ..f ~ a , % • ~ ~ :a n ~ ~ ~ ~ ~r ~t~ fi~ i, v ~ ~ ~ 4 = ii`~` ~ Q~ 0~`'~.,,.~~~~~;.•• _ Conat~ Health iaer and Loasl Registrar , ~r, : ~ _ ~ ~d 0 B , ~ ~ ~ ~ ~ ~ ~ . ~ ~ . - . . ' • , " Dspnt~ Looal B~giotr ' . - , _ - - . . . FIl.ED AND RECOR~ED ST. ~UCIE COUNTY, FL,A. RECOR~ VFRIFIED -14 ~pp`7 ';r OC~ 7 ~M 11: ti~ t :C'~_F+ ~•J~ F ;S CIERK CtRCUIT COURT ~OO~S~ ~p~ d ~ T. . s~' } 'q, ; . ~~s <q.~ 's1 = ,~~,`'.a r; '~'or~ . s3, ' r »§~.m ~ . _ i