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, OEATH VERIFICATION
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f. SEX i. COLOR OR lACE f. YAlRIID~
t~w~s~ QATE OF tIRiM f w~M~~r~° ~ or~. t ~ ar N
1Nl001NED.
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OIKTtY WHAT Cv. .~TRY1
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13. FA1NEt'S NAYE K MO MAIDBi U/tMi
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1S. ECFASE~ E11ER IN U. S. ARN~ FOR~Bt 1b SOCIAL SEC11l~ 7 RMANT
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3]~. ~CtaeR SUICDE MO~YCOt 2fa. oEftrE NOw tuRT OCUAtIt~l ibtitR s~tw d ii~ivs iw Art 1~? A~rt II ~f ihw 1R1
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~ 210. 1111E OF B~r 1I~t~. D~ Ywr
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' 21t lt~RY OCMl~ 21d. ltACE Of NJIi~ I-. iw w~iwt ~w. tl~. QIt. TOMIM. Ol tOG110N QOI~AY S1ATE
w~on~"T ? ~ ? ~~.a.s..a~.R.o~..+++~..a~
n ~ kaebr caa/r rbat I.uaJe~i t~e leceye~ /ro.~ - 2 ._14~`~G - l v . ~y ~1 rl~t t lsse .ta~. r1k dasosea
Jix oa~~ -/!J . 19~, ai t~tt 1cstL occmred /row tlie causes and ow tlk date stated oboae.
2~. D iE St Il?. /1DDRESS 6NATU cwn.. .e mu
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~OR CREYA- lrb. ~AiE 2k. NAME F CEYEiERY O TOtY 2W. LOCATION taa. .r e..wt ~aua?
~EMOYAEc ' J/
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250. DA i ECD ]S~ SI ]L. DI ~~%`~G t
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~ ?h informetion givea ebove wea copied from th certificate of death ~vhicl~ ives filed ~vith me for !
j trenemittal to the State Department of Sealth for registretion as provided by RRS. 213. Certified copiea '
ot the officiel deaW certificate mey 6e obteined trom We Oftice of Vitel Statistics, State Department ~
of HealW, 275 Eeat Yain Street, Frenlrfort, Rentnclry, for a fee of ;2.00
/Z--1/-67
~
te Local Registtar
Couaty Healt6 Deport~ent By:
eputy egistrat
rentucky por¦ YS 105 (9-SS)
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~ ~~C~E COU:JTY, FLA.
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~ 162'758 ~
'sl DEC 2Q AHI I i: 44
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CL~RK C~RCUrT COURT
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