HomeMy WebLinkAbout1428 "'~'i-°"'"'~'"""4 CANAL. ZONE GOVERNMENT 1~84 y
CERTI FICATE OF DEATH ~~.s No.~~
_?~3 ~
IN ~
CANAL ZONE ~~2
l. PI.ACB OF DBATR ( i tl.9UAL RBSID6NCB (WYn 6d 3eared i~t)
i TO~PN OR Pl.ACS I a 0~~~ ~~~a~d Ooa~t~)
Ca~al Zone -
AOBPITAI. N N0~1' Y H~L p~ ~t a
d~~ a~ d b o~
i o s) h C 1
1' Y O
R '
P
O
W N (
U e a f~ d ~ i~ a ~ R
i J R A L)
(~'~A ~j~trtl T.1 BOO< _
iBN(iTH ~F '[IYE ON~~ a ~t N nral. ~iw Ioe~tio~)
~ ~ gQ1l0A ~
IiAMS OF O~CSABBD ~~(~[mt?)
F DBATH , (p~)
('lyp~ ar Hid) HAt.},~i J~ ~+~lA~Z
b. SS7[ d, OOIAR OR 7.1tARR~. 8IN(iI$ E. DATB OF 4. Ad8 (ta IF IINDffit 1 YR IF ~NDIDt ~t8.
~?~g IVOR~ BIRTA IrE b~ l[atr I D~ Aan ~ 1(i.
F
IOa U8UAL 00(UPA1'tON lm. RIND OF Bi18IN~'88 OR IIJDDSl1tY (it ~spb~M d~-
asa p~d (7omPw or (~ial Zoa~ (ie~~r~sR ~o sta~ aod ~
~ ~ RAt.~~a ptTl~,t Citl'1L1 CO• l~OyeA Ba~ew ar Di~i~ion yd id~stiia~ ~ob~r)
i t. SIATHPLA(~ (SbOa r 1a~'~P eaob'7~ ! 12 CCCIZ~
~ p~` ~ ~
13. FATHBR'S NAl[B ! l~a. IdOTH~tB MAIDEN NAIdB I l~. 3POt188'S NAI~E
~ p' 9imon Jones I - Jlnthoav J. Zah~
~ is. Wes r~ n~cSes~ sv~e ix u. s. ~x~n Foxc~r ie, socw. s~rnn~r oR ro~r-
~ ~.e,w ar ~ ( N 7'~ t~ ~r u d~e d~ia) TTFtCATtox xw
; ~Q + ~
y~ ~ ~ 1R ~AM' (8p~+rr ar I 17b. ADDR~
~ ~ - g0 tiil. Q~1"fi
1aCAI18Ba DBATH TIMB BgTWS6N OODE
~pr ay aas aww _ ONSST uin DB~ATB
v~ r~.. ro. te). 1. DI88A8B OR OONDI'fION g~~},~id arEhri a ?22.0
~ ..a (e) nn~c.-rt.~ r~ntxa ~e~o n~~• c•)----------------------------•-- ----l---------------
•~c~.. a~....~? ~ arn~c~osKr esuses p~ acute and obroni .
~ . .
...~n~iY'~BnL?TS 1[«eia emaifieo~ if +~ss. O~c e:• to To (b).
CA086 d d~~i. ~ot ~ ~
~ ~+~t ~ ~7-
ti DUS
~ ~od~ d d~rb a~ Mrt
~ ~ TU (e)----_.._--------------------
r.~..r +~n?~. )
: o~ s~c~xtFtc~rrr ooxnrr~oxs
~ ~e~tioO. aooa~ut~ ~o rb. aesti but
uot ~alaRed to f~ d're~w ar aoa~fioo
O doie` de~t6
~ + ! 19a DATB OF OP~t 19b. YA~OIt FINDINCB OF OP~tATION ~ A~~
I ]t
• ~ ATION YF~ ~ NO p
' ~ ~ ~ _
i ~ !ti AOC[DEriT (Spdf7) =lb. PLlICS OF INJIIRY a or 21e. (Qd~r or to~n) (Camb7)
W _ ; ~ am~!~mit B - ~
~;,rm, f,darp• ,treet, o6oe
~ ~ ~ ~ . • ~ ~
~ ~ ~ - ~ '1'fMg , . (Dq) (lfer) (8r•) 4w~
~JUR
N~O~~RED 41t. HOW DID INNAY OOCQRt ~
~ ~ ~g. Q ; '
~ a~- 1NJtJAY ~ m. wak p at snrt p S
/ ei~ri~ji~f I~flea~itY Jra~reil^o~ -~tt-9 19_~ N_.~tiStLSt.-~--~ 19_~.1W / Iat ~uo W Jnw~~
67 W'~ / ~ • ,
N'; e ~ ~a«y.!~t-~__.~~_~4..r~~.~..~.~12z45-py,~~~..r..r~~,~.w.~..~
~ ~ ' :7~a. SIt3N~17'URB" - - (Depe~ ar titL) ( ?3b. ADDRFS3 2'~e. DATS 3IGNSD
~ ~ - HO]C ~ ~
t ~ ~ K D.
~ ~ SURY -(~ATION. DA
i 1 ~O~ATO`AY~tgf~tY OR 2~d. LOCATION ((~h a ta~
n~a7~
~ ' ~ $F.ti[or~ (~.ary) I I I
~ , ~~~~'4AM ~ug 5, 966 s~taa Crematorv Anoon_ C. Z.
i DA'[E RP~~BD BY VI- SI(lNA1VRS OF V1TAL STATLS17G8 CLSRK 25. FUr'OtAL DIItDC1~OR ADDRE88
s ~ ~ ; I 8 ~ '
$ f
~
- - FILED AND RECORbED ~
~ ' ST. LUCIE COUNTY. FLA. ;
~ i•c'rn~t: ~'hIFIFD ~
~ 1~09~84 ;
'61 OCt 2 PM 12 : 3 0 ~
~ ~ i' : ~JIT F?: S .
CLERK CIRCUtT COURT
a~K 168 1425
~
- _ _ _
_ . _ . r _ _ _
- -