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~~~Tn,~ D- , f T~TA7t ¦o~a~ o~ Nu~~ntY CERTIFICATE OF DEATH
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• •YRUIJ OR VITAL fTAYli1'IC~ lYATt~FIL
~~a•1 FLOAIDA
ord •A~e BIRTN NO. R[GI6TRAR'S NO.
pro ~lr Y~YAL w«t0[KC[(AMnMrrtlirf. lli..a~w.~ R~ibrld~+~wW,
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! n CITY. ?OM1M. d! lOG??~OM t. ~S tU?CE Oi DEATN t. pTY. ?Ow11.OR tACAT1pM t. IS 11ES~0ENCC .
(NSIOE CITY 11Y1 1 INSIO[ CITY IIMITs? :
Pompano Beach resp No Pom ano Beach ~res ~a
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1. tuw[ oF (/J~wt f~ ?wyihi. f!K ~trtd ~Ifrtw) STREET AooltEti
~ T~Ta North District Hospital 270G i~. E. 1 Terrace
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~~v~ M ~.ia~ CRICSO\ , ' °`"T" ~
i. S[X i. OOLOR 011 11ACE 7. MARRiEO~ qEYER MA11111[0? OATE OF ~UI7N A6E (/w tta~ K u~0[~ ~ tw 1wot~ s~ ~f.
tYt Wtlp/1 Xwu. Ww Mww 1..
~r t• ' vnoowco p oiwacco J a ci . ~ 1894
y 1 a 1 a 1 r IO~. USUAL OCCU?ATIOM (Oflt lIR~ ~/1rMk ~~t 100. KIKOOF ~Y5INESSOR WOVSTIIY 11. ~IIITMKACE IStdt M~Nt1/~ Nnnt111 1 qT1iL10~ O~MT
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Dl~ok lwk ~ ~ATNE11'i NAM[ i~. MOTNCII'S MA NAME
er
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IS. WAS DECEASCD E1fE11 IM Y. S. ApMEO FOIICESI ii. SOCIAL SECIlRITY N0. q. IM/O~ NY Y
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no...t....? none 184-03-5~136 ~~~++270ti E.
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d 1 r~ e te ~ ?AIIT 1. OEATH WAS CAUSEO ~ri i ,
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r~ a i~ t r~ r ~~i~I t~?t r~Qr- ~ TO (t)
• i t A l O T~ 2 ~I l~rK 1Nf. . WAS AUTOKY
f+o u ~ s ~ t- F ~AIIT IL OT1E11 SICNi1CA1R OOMOIil01~f COMI~NIRM 10 DE~1M ~ NOT Wl?lE~ 10 M fUU11~N106Gf[ COM0ITON GIYEN M?J111T I(~ ~IIiO11ME01
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o r s• t~ r~ ~ IO.. ~ ~ 70e. ocseanc eo~r uuuer oaus~a (a~.te...wr~ N~yw~ b p.t t r Pwt 11 y~rn~ uJ
•ak1a~ ~w~ ~ ACCIOENT SYICIDE NOMICIOE
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= I01. IM1u11Y OCC111111E0 20t. rU?CE OF IMJUIIY (t. /..1~ M~Mf bwt. m/. Mr. TONM. OR 1OC11T10i1 OOYpTY STATt
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WOIIK AT WORK
. 21. ~~tt~nd~d th~d~qd/~oa~ +bl . fe ' ~ ~ndl~~twr ~ ~ ~li~~on ~2Y~'~-~
D~~th oeourr~d ~t ~ ~ a~ en fM d~h ~f~t~d ~bo?~; ~nd to !!N bpt ol a~ nowbdj~. /rom th~ auN~ ~t~f~d.
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e • iwunl. CI1F~u tlt. OAT[ ik. NAM[ Of C[M[TEIIY Oi1 C1IEMATOIIt 2U. LOCATIOM (Cit/. lw~. M sw~f/) (6tW)
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g ~`Y°"~`~8"`~ Hol Se ulcher
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~I~c_ca ~r wc~ aca .ti. a T e•s sw~u '
a•~•ioe• Pom ano tieach. Fl . r0~.3/ ~:e.cc. `
RECORDED IN Of~l R~~~ O~
oF epow~c oouMt~t. ~anos a~ ~
JACK WHEELER • ~
CERTIFIED COPY ~E~( OF CIRCUIT COURT m ~
~
2
; I hereby certify the sbove to be a true and aorreet copy of the Local rv
~ Regietrnr~a reaord on file in the BroWard County Health Department at
~ ' Fort Lauderdale, Florids. _
~ (Warning: Not valid unleas raieed aeal of the Bror+ard County Health '~s =
~ - Departnent ie affized.)
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~ . . ; _ ~ • ;
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; ~ ~ - : ! - County Health Of aer snd Local Registrer ~
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~ , . . y.~..:.. - . a~
z~ . : - :
y ` ~ ~ ~ ` Deputy Looal Regiet r
~:j FILED APJD RECOHUtu ~ ' '
r~ S7. l~C1E COUNTY. FLA. • ~
~e t:~.nn: . -^r- -r~
tis~ 1652_~'7 /
~j ~sa ~ I 4 PM !2 : ~ s
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CLERK CIRCUIT COURT ReturntoFles~istg,U'~y~nu~ler.-~::~~ ~ ~
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~OlR1K ~~U FACL 1~ ~e P. O. Dra•r. cr f>' i ~
- fort Lauder~~;3, r':.;.:.., 3r:;,~;-4
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