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HomeMy WebLinkAbout1832 ! . ~sow? R~rs av~ w~TM s~wts s~s Mo. ; ocT ~ ~ ~ ..~..,~,~...TM„a. ~ . a wo. CERTIFICATE OR DEATH ' RsoirrRwR~ no. 0 i ~ A. COl1NTY • a A. ~TATt ~nO~efA~q uv M M~~ i co '"$"mo~":" ~'i~'" I 11 i noi s ~+~+~r~a~C~e i~ , C~ 1N CITr ~IMIT~ C. CI~ CITY WIIT~ t' roww Phoen i x D o~*s~os u*n uMr» ToMn+ Munde 1 ei n O o~rr~NSan? awwr. ICE . : a FuIL w?wa ~w Macr w~ No.nriu. a~ u~nrruTa«. ~~vs .rnssr a srRC~r ~H? Rwu?~ «rs ~oonro«~ s. ~s Iq~owas oN w~wa~t MOirITAL o11 O11 Tq11! AODR[fE INlTIT~lTION Yq Np . NMAE OF' w. ~.wr? ~w...q a t....~ 1. ssu oo~o~ oR It~s ~r~...~ar~wew ~ oECE~o Sidney Emerso~ VanTuyl awle white / ~*.~so~..~~ M rried . NAM[ Of ~01~K 7. Ti OR IRTN AG[ ~u~ • 1I ~ tiAw 11 Y 3~ IIM. ~A. Y~YA6 OOCY~ATIOM tMtK a~w M ¦MI?M Mt fW WT ~u11MO11t! MOMTIM i~t~ tlOM"~7 rM1. ~Mt M1YM 1~O~T M LIR f'11fM M~Mp1 . Hazelle 1 12 908 59 I Owner-VanTuyl Engineer / •s. KIN1~O{O~R Wil. 10. ~IIfTM~J1C[t~T~~~ 11. CITIZEli OF WHAT 1!. Ww~ D~CiAKO pq IM U. S. AItM[o /pwC~tT 1~. fOC1ALKCtlRITY ~ ~E~achine y`Y ~ansaS owsm~ u•QOVNTwYt ~.~.`.O.Nw~~roww,I t~su.aua~~+?TUw~s~?~w, 45_'b-6737 S A ~r • ~sw. Fw~cR•a wws ~~s. s~~K.wca ~a~. Mon+cw'i MAlO~l1 NAM~ ~as. ~i~r~wcc . ; Th«nas VanT~y1 Iowa"""`°"""~, ( Laura Emerson fowa ~ ~ A~~R~u 1=. A IYOMfNI IOAf~ ?W1 t w=!t~s; 'c:.~ Mundelein, I11 i noi October 9 19~7 ~ ! 8. GUJSE OF TH . ' ~ ~o~ wir~o o~cwTM ~w~ae pu~ owa a',.w~s Kw 1. blslASE OR CONOITION ~ - f ~u~ Io~ tw~. 1~~. (C?. DIR[CTL.Y LEADINO TO ptATNt '~A1 " . • . irww eos~ ro~ ra~r Trs ANTECtOENT CAUSp • . ~ . ~ ~ws M w~w. wrcr w ~MO M/1NR OUt TO t01 MtYf IY?Ywt. w~TMlNM.- OIYIN~ ~IK TO AWrt . ~ . ate. rs~r~ irs NwwN. CAYi[ tA) RATiM~ 1N~ YM- _ ~ o~ oow~wsww oc~r~N~ cnuat OU[ TO 1C1 ~ ~w~ew ew~se wtw. 11. OTHER sWN1 fiClllfT CWiDITICNi . CONOITIOiN OONi111~YtIN~ TO TIIt OiAiM WT NOT • . ?uu a~[~~ cowiuc~p. R[IATINO TO *11[ OIitA~f OA COMOITION WWI/N O~A?M. ~ lY O1? OF TION lY . R DI_ : " ` 2. AUTOPaYt : _ ~ M!s ~ N0~ • ' ~~~~.~~.i / 21. 1 NtREOY CtRT1~1f 1NAT ~ wTi~MOfo.11~! q~cwsO r'ROM._~LL 1~ ~ ` 1~. if1AT I WT ~Aw TMS o~ew~p . ALtY[ Ol~l~ ~ D/~ THAT Af~~ wMp ON TNt oAT[ ~TwTto w~OVt. ~,Jt~~ 2TJ1. SIGPU~? a~ ow nnn :ss, t.. _ tt~.O/ ~ s~ co . i 1~' / - 2~A. ACpDENT M[C~l11/ t90. M.AGE OR INJl~RY ti.o.. M1 ow NOMb .=iC. .~C~Tt?oRTONnq lCOUN*1t1 l~Twip sIJICID[ - ?IW1. /Aa/M1?~ ~1RKTi tfi'~qt ~D~.. iTC.I ~ l~tATIJRAI CAUS[ ' 23D. TiME t~*r~ to~r1 Ii~! tl~ows S.1e. Iti,WRY00CtiRREO t~F. MOW DID INJWtY pC~.'UIl~ ~ E ' ° V~ WN~u T Nvr ~tlw~ ~ - 24A. GORONEIi'S i1dNATURE , . 248. RESIi . _ ' 24C. pATE i1GN[O F . . ~ ' - - ' t, . 2dA. O AL O 239. DATE 26C. NJ1YE OIr GEMETERY OR CR[MATORY - l6D. WCATION ~ps~, wir~. o~cwrn~~s*wts~ •T' "~'"°"•~oI _ 10=10-67 ~~eet~,rood~ Ctea~atory . Phoeni x, Ari zona . 2aA. OATE REC. I~EOIiIRAI!' ~iNATURt • 27A.. FUI'~ERAL DI ECT~pR'S il~!!A?LRE 7S. AOOR~EjSf - T, j~ ~ BY LOCAL EG. I'~ +R f 1? /ull OJl~ N• - . J 6 C' ' ~ - s~rqnuint• s~aywTUec :ss: ~xewu~ue•s . . ro~r ~s-a ~i~. ~.~-N . wr ~l ~~.0'~~.~ . ` CERT. NO. Q , . ~ ~ fi ~t - CERTIFIED COPY OF YITAL RF~CORD t_ ~ v~ S?ATE 0~ ARIZONA ) - ' ~ as Date Issued: IOCT 18 -i967 ~ , COUN1'~T.. OF~ Mllltl<~OPA) ! , ; i ~ 7T' . ~ ; : ~ ~+~~'h,{,~.~, ~ia a true and exact rrproduction of the docusent officially ~ "~~gLs#~e~e~++n~f'placed on file in the BURBAQ OF VITAL S?A?IS?I6S, ARIZ~TA ~'..a~ _ ~~~$~~RT~ Ol~ ~BALZtI, PKOENIX, ARIZONA. I.= , , y j y~j~~ai~er=.the authority of ARS 36-327 ~aad by directioa of: . . . . ' ~ , , - ...s , , : ~ ---~;``~F--. i ~:,~e- : . _ • =s . ~ . r. ; ~ ' . ~ , '~u~~v~ GEORGS A. SP~NDLOiVS, M. D.. M. P. .8. ~ ~~;g.. _ ~ ~ ' Com~issioner of Public Health , ~ ~ , :pgpufy~-8~ata~~tegistrar and State Registrar , ~ ~S COPY NO? VALID UNLESS PRE'PARED ON SAFE1'SC PAPER DISPLAYIHG SYAFB ~ SEAL-IN CpLOR ANB D~RESSED WITH RAISED S~AL OF ISSUING ACENCY • ~ ~ _ . . ~ FILED ~ND RECORDED ST. LUCIE COU~JTY. FLA. :.r ~ :F::~~!~D 162'?'13 '67 DEC 19 ~,~1 10: 34 ~Y' ~ . . ~J'+i=. CLEftti; CIRCUIT COURT ~~K ~69 P~:181~ -