The URL can be used to link to this page

Home My WebLink About0289 -15'7'790 t~is De- BTA7E eonno or Mcw~r+ CERTIFICATE OF DEATH ~ ~ 1 ' eoaea ~ PURGU OF VITAL ~TATIfTiC~ 1TATt, FILt N0. FL08ID]~ ' ord .Aen PIR7H NO. REGI~TI~AR•• NO. pro~erlr tuCC Of OtATM COD! NO. ~WK~~A~~'~~"'~~ f/iwi~t.w: RM.r~W..~i.w:..1 e i e e u t~ d ~MTM STATE ~n 2 .pa I3rev~rd 15-066 Flor'da Brevard pe *l.e.a e. ~S I1ESiaNCE in p~r- 0. CITr. TOwM.On IOCATION t. t5 ~IACE Of OEA?N t. CI1Y. TO~.O~ IOCATION ~N510E CITr Ur1TS1 ~~q~p~ ua~oc cm? uMirn j{elhourne ~?Es r, rie lhourne .ES D No p l, NAME OF (//w~t b~Myifd. ~wt Ibaf ~IlrtM1 STIIEET ADO~ESS ~ ~ T~`a A~orninRside Convalescent Centcr 185 Avenue R. S:~' ~ 3. ru?M~ os i'ir~t A/Npr Lwt a?TE A(~d D.t Ysa oucwuo }~~T1C@ (nmi?) 1'lOOD _ a°~`?rM June 28~ 1967 (71~v~ ~r piat) S. SEx i. COlO~ OR RACE MA11111ED ~ NEK~ MAlIR1E0 OA1E Oi M11TM A6E (IR ~q ~ uNO[~ ~ 1rw urocA t~ wK. .TLIiV 12 1HQ1 M~rM Ow Mwn 1fh. r c. ~:31C liihite rinoowECO • p i.~ 01 r ~o.. uw~ ooeu.e•aN eo~re ~rd N•••~ Ka~o a wsu~css oR wous~r ~ a~nau?a ts.a.. M•~r. asae?r~ i ama ar .nw~ aa,¦r~r~ •1~s v•~- ~••~•.••~y~«~~.~.~"+/~~'~ i1n in h.vn, Rradford West iISA ••~•e~ rin isher tlat ttanufacturin llaelc lnk 13. iATMER'S IMME 1~. ~T~~~ ~~p;:~,~.~ .Tohn r:d~~ard !~ood rt~ry r~aude Roe li. SOCY?~ SECUR1Tlf M0. 17. • NYNI1TYAt A<M~M 1C0 ~S 0~~~ ~1'Iho ~r_~,~c~ ~ b~6~ 185 Avemie A. S. W.. ~~elbournc, rl~. Fun~r ~ l 1~. CAYK K O~ATN ~b1Mer w~l/ ws eMls p Ii~t (S1. qt (tl.~ IIfTERYAI /ETWECM ~ART L OEATN M~S CAYSEO w: - OILSET AMD DEATN , ¦~~tet11• 1MMEOI~TE C~41SE (d ~ ~ ~ L ~ t sA• e~r- ~ ~ ~/1 ..1~/,(_ I ~ ~ t1t1e~C• Cq/ifi~a.//pI. OIIE TO Gi3./tM. ~?s'I [L ~ •1tA tA• ~rlid /rs b F ~ 1 o e• 1 ~O~r~ t~wt~i). 4 r~afstr~r ~t~tiy fAe ~~le?- OYE 70 (t? ~ •Stala T9 fl~~/ n~us l~t. O NIRT fL Otli11 sic~ric~r ooia*~o~ oo~wurws ~o ourn wrt ~~~s fo tMt ~ o~sus[ to~ana C~ w~r 1(~) • wA5 AU70?SY Aour• •t- F KRFOItMEDt t~f d~~t\ s Oi O~rO~i IPrW~ OESC~I~E IION Nl11MY OCCYRAEO. IE'Af011~fVt ~/I~~ ~R PMf /M Prt II ~JYM /I.) ¦~Iclps ~~7 ~ ACt10EMT SUICIOE NOMICIOE dl~pe~t- v ? ? ? t1011 J~. TIME OF HNt xMl~, Dt~. Ytlf ~ed7• ~ uuu~r s. , - o p. s. - W ~ 20/. ItUUII~ OCCY1111E0 mr. ~U1CE Of IMlYl1~ (t. i~ M dM~f w~t. mI• dTY- lOMll. OII lOG1T1011 001111?Y STATE ~ ~ Yn~LLE AT 0 wr wNnc ~ /«i.?r. arreet. ~cs ay. ete.) 1M~11K AT MOQK ~ , ro Jttnc 2R~ 1~J67 .,~r..r... .r..~ ~ ~ 1~tt~nd~d tM d~a~a~d Irom Aim D~~tA oeaurnd ~t S: 1~~ ~ m o+~ tM d~f~ ~f~Nd ~bo+~: ~nd to fM bNf of aq kno~1~IN. IfOQ1 ~A1 C~YNf a~~l1A. ?l i f c•¦s ?L. w ru~c (Drpa «wk) t28. ~oo~tss 7?r. wrt sw~o ~ i •r• so D• • t. ~o.o~.c. • i t•1. A. - Indialantic, Tlorida 6-2R-67 •et~?~t~. 23~ ~~t. rqil OATE Lk. rU1ME0FCEMET[~r011CREMAT011Y 23/.IOCATIOM(G~t/.lwrn.~rtw~f/I (Sdt) Re~- eri°ite~ .Tulv 1 1~67 Ft. Pierce Crematorv Ft Pierce, St. )ucie Plorida v. s. t e~ z ~ -s s~uuruac ~oo~css 2S. OATE RECO. ~Y LOCAL IlEG. 6KTItAII'3 S1GMA7URE a... ~9as~.., : ~lelUourne, Florida a ~ ~ ~ - ~ - - ll~-c-~~~_ . -~'Ir I~EREBY CERTIFY THE ABOVE TO BE A TRUE AND CORkECT COPY ~r hr. RECORD ON FILE ` i ~_•IiV THE LOCq~RF.GISTRAR'S UFFiCE IN THE BREVARD COUNTY HEALTH :;PARTMENT. ; : - ~J~ • _ (Not'.valid un~ess the seal of the Brevard County Health Dep~rt.....:.~ is affixed) . , 7 : ~ ~ . ~ ~ ~ ' ~ ~ : ~ . ~ ~ i~~37 -~=7`' . ; ~ Deputy RegistrEtLEp AND RECO ~ ST.~ECO~RD yVNTY ~ED . ~RIF1Ep~. '~l .~1~~ - JUL 10 ~ 8 : 51 ~ CLE$K ' ~ ~S BOGK ~~v~ PA6E 2~~ ~ RCUIT ~p~Rr . 3 ~ . ti - _ ~ , ~ L _ _ _ ~~X~' Y."`.~.,~C ~ ~ 4~~` x - vi.~' : 4 ~y . . . . ~ . _ .