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HomeMy WebLinkAbout1670 YICROFIIJ~I l~i/p Legibility oi writing, typing or printing unsatisfactory in this ~docmnent ior ¦icrofiluing .i.~i8~1.~ . , . . FILEO AN~ RECORDEO ~f ~ • ST. LUCIE COUNTY. F~A. r~~o~n v~c~s-ir~ r30 L@C C O f.! 8d'T'V ~A!_'9'Eh1 D~I~ARTN~ E~IT 1F841~ . . wiu~wM o~~ccTO drt.. w.a '6U JU~ 3 W7 • S~ o. eox ~seo r--~. _ :sa wvr~ua o. N. w. ~~G • ' WINTER HAVEN. FLORIDA ~ Q~'r~~ r;~~: se- 6TATE eowaa of KEn~rei Ci=:~ 1 I: IC.~ 1~::: O: ~ DC~0.1 I CLERK CIRCUIT COURT ~ caaes • BUREAU OF V17AL G7ATIOTIC9 S7AT6 F~L6 NO. :z~.: Fzo:~YD.~ -~~3-' ord ¦Aen A~RTN NO. REGISTRAR•5 NO. ; cope~lp ~ GODfi iVO. Z. USU.^.l RhS10ai:CE(tf?ntt~ffti~ef !!ivt:t.t.~+: RrNe.~~~Nw~~i~wwy+) .•cceuted PNCE Oi OkAYH STAiE 1/v~~~Q A. COUNTY ~ COUNTY 'L 2 n r~,d ¦ 1 l 1 ~~(j,(/t ~ ~Q,J+~ I V~2 _ Le pTiTld A IS RESIDC~tE t n pet- O. C~TY. TOtiYN.ON IOCATqN l. IS PCACE OF OEATN t. CITY. TOWN,QR LOCATqN tNS~DE CI1Y LIw~25~ .+~nept • / 1h510E dTY 1W1T5/ ~1~. r? i e. •~.I.ILfP/t y~aven res 0 no ? ..1./t~PJt I~UVPJL res ~ J. NARlF OF y" J. STREE7 AOD11ES5 (/Jaot i~ ~w dd, yiss ur~rl sfd~~) 1tO5PITAL OR ~~L tNSTITUTION .~,C./L~PJL IyCCVPJL IUVAO<.~ IO~ - ~3~/~ S~P_P~ ?oGG~~i. Q/J%E ! ~ ~ Fi»t Vi:dfe Lat ~fo~t~? Doi 1iw 3. t1Af.:'s O/ DATE -t 1 O~CEASEO 1 V f t ~ ;j,'~CIL l`~ ~7(JJl (TYD~erpi~p ) ~~t1_a~ ~'1~ ~::.1`'l~l!1.~ ~LLI- oU? H . ~ ~-t 0. DATE OF BtRTH 9 ~GE 7tnr~ ~~Q~p ~ TFM ~;~p(A'~ NwS. ~ S. $E% L. CO:ON OR MCE 7~ ?1AkHltO (1' MEYERMAR c0~~ t'. ~ F , ~j lc~.%If(~(~1) K~ty Mas Il~r~ Ifi+. ~ ~f r 1 t• f~.G~~(~ .~~~e 1YIMClCOI~ dYJAfEO 7~7// J ~ ~ ~~>"I3- - ' 1 n 1 y lOu. ~~UAI OCCUPATqN (Ci[t tiwd o~r~ork Soqt iCD. iCIK00F C~iltitSSOR IV0451NY I1. Gt.111:?U1CE (,7dt W f~?tIJA tJttqf?r) 12- diREn Ci tiNAS COU~I~Yi J I tA p~r- durin) InWf ~Jrwki~/ 1iJt, «en ~/ntind) r; ~I / ..+nent f'(!/'Jl:~Ui. ~~I~ t 4~<.NCI/1~ ~C'lil1P~J4C~G _l. S. 11. ~:wcY 1~k ~ATNER'S NAME 14. h:OTHCA'S ?~~~DCN NAwE ~ ty~~rrltee ~i~R. vGU1IP/3 ~Q/t:~fG'~L~.~ P •Q/r/LPJL 16. SACIAI SECUR~TT AO. D. i:LO :0.:A: i SiGtlA7U.-•s Addrw fY~ ~ c_ 1 c- ~ ~ /v' - /~~t S~1t~P~~ ,~U•t~:'t ~(1~3~ ?_v~ 5;-,/!~i I )~~iP~ ~j . ~n,~G.~-r,=~,,~~ :.crr;[~c ,~ccven, r.Co~ur.rc ~ ~~~ncr~l ~ 18. CAU:C Of CEA7:f (t:wtt? osl~.oet c~we rtr Gna/nr (u). tb). ~n~~l.~ 1\:E~7YAL GU:C A ~ iART L DEAiiI WAS CAUS[O BY: ~ ~ ONSET AhD DjATM I dt~ettof ~ au+t fll• IMUEOUTE CAUiE _ _w[1 ~~'~'t.f/~T<~•L~C• ~ P~Uft/_~~t~ - _-4~'~,~i~- ~ ~Le eef- / ~ Cifte~t• ~ Condilio~i. i/~s/. OUE TO (6) V------- - k , i: n LA• ~Ai~• ~~rt r~~f to i o e w 1 aboet c¢ru (a), ~ re tstr~r ~nlin/ Ut r~Qt?. - - F /~iq/ t~ux lwl. ~E ?O (tl ~ •SLAln 73 i.\tiASAUTOMY 4 O PART O~KR SiGA1iKAA (A.YqiqNS Cp.1R17{lTIYG i0 O[ATN DtR T REUTFO TO iHC TLANtML OfXASE COKD1T10N GIYEM 41 PART 1(~) t i~ov~s a~- ~ / ~ ~ PfRfORM[D1 ~ c~~r dc~tA ~ ~ .lj vj - _ YES? NJ~__ ~r Lefo~• ti ~ 2Ofi. DESCNIBCIWW INJUBYOCCURR[D. (F:p(t?q~f~rt0/isjk?~i~ P~~[ IW Po?f 1J0/iltw/la ~ 20~. li'~oL~ I ~+YInR •n~ ~ ACt1D[NT SUICIOE HOMICIO[ Glsyost• ~ ~ ~ ? ' :on o[ J 20c TtME OF /lo~? Alowf~, !H/, Yt~r i ~°d1• V ~~+JUNY q. { ~ p D. w. w ~ 20Q. it~:JURY OCCYRRED 20t. VI~C[ Of :NJUNY (t. 1r1 O/ ?M~a! ~OAt. 2% GTY. TOWN. 011 LOCATION COUhTY SiATE riM0.E AT ~ hOT YYN~LE ~ /•~w•l~~a~. Wr~rt, oDfu Wd/., Hr.) WORK ATINORK l ,L 2~ • / ~t fended ths dece~asd bom . ~~-V • ~0 3 _ ~nJ laa~ saw~h~~ ~lir~ on ~.7. ~ T ~T '3-~ a Deeth oceurieJ ~t _ _ m on the dsts a sted e re; ~nd to fhs beat of m~ orJsd~s. (rom the causea itat~J. ~ A:1 lte~s jjs SICriA/7 UAC (/~vprttW/iflt) / 27b ~D~RE.,S~S 22t. 0~1TES~G~EO ~ ere t0 D• r~/~Q/1 /~~'r?L~L~/l~ ~l il~ • ~YN"rwl ~YQ'v`~! ' ' ~1 /l~~ ~ eoap3et• ~ YV 1~ ! • t t Yf ~ f.f • ~ @;1R;~L. C~EMATIfi~/. ~ DATE Z~t. NAME OF C[?~ iAY OR CRC MATORY 23d. IOCATiON (Cd/, (OY'11. M fObN!%) ~.~f.Yt~ ~rwoY,<<tii ~yr~ r ~ ~ Y :~'~:,r~ ~.~r,f ?a~. /J, ! ~G~' ~~~ve~ ~~T~:le~~i l:~s~i~.~~CCn %.~~,n~.s-:~z ' ~ - : - - Y. S. ~ B12 I~. /~'~~•~A~ j~~R~CT7r S SK'" TYNE A~URESS z5. OATE RCCD. BY IOC~I REG. 26. REt;ISTAAR S S~GtiATUiiE ~ :,er.1~6b 1 ` 1C/- ~ ~i,~ !l~~..~ ~~~.:~j, 3"~ f~C,'ta'~ ~.~.L~~~`Z~j~.V ~~~.r'- ~l(~ ~ • ~ ~ ! / ~ / / ..~•1,~', ~ ~ ~:.e: eby certifp ~hQ_ ab~:~-. Q be a true and correct covy of the Local Registrar~ s r~c~rd ea~ : ;~:.Ie irs the Oi'f`ice-`o~ ~,lsa`I~~g'~IQN OF VTi^aI, S~"ATISTICS, at th~ POLK County Kealth Depart~.ent - . ~ ~ ~ j•lItrTII~ I~ii?Vr~ ~ „ . ` . FLO~! ~ ~,~~;rning: I?ot vali~~_,~.1~s-ra~s~cr-seal of the DNZSI02i OF VITAL STATISTICS, POIX County ; Health pe;~or~ment i~ ~'~ix~ed. ) ( ` ` ~ . ~ \S . 'n • ~'r ' f ~ S : ~ _ ~ ~ ~ i ~ ~ W ~C/~Gr+.L i~ I ~ ~I.,~~.~`~ ~ ~P E ~ , , - County Health Officer and Local Registr:.r ~ ; 4 R~251968 AL . ' ' 3. '~...~...,.5} i# Dep County Local Registrar ! aODK~~z ;h~;~s~~, ~ . _ _ _ _ ~ >~r ` _ - _ - ~ - r -