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HomeMy WebLinkAbout1122 ~ . _ ......__Y-...-.--_ TAIs D~- ~7AT[ HOAAD 07~ H~?L,r,~ ~ CERTIFiCi4TE OF DEA7H co~~s • iURPJ1l! OR VIT/?~ i7AY1471C• S7Att 11Li NO. ''a'' .LBS~QS F L O R I D A °t~ ~n~~ BIqTN IJO. REGISTRAR•9 NO. prop~tl~ •:~tut~~ 1.lU1C[ OF D[AYN GOOE NO. Z YftJA~ 11iU0iNCt(M'~.~fr.wdti~.L !/:~.r;e.4w: RrJ..uld~nv./w:~j • n d ! 1 ~ 1 ~~NTM STATE OpYNTII , D~ 8ra~ard OS Florida 8roward 1 n D~f• CITr. TOMfM, Olt I,OCAZ~OM f. K 1UCE Oi DEA7M t. GTY,1pWN, 011 IAC~Tqi1 e. IS 11ESiDt?KE ¦~q~~~ INSIpE CITY LINITST ih510( CIIY IIMITSI ` r,~.. HoI2 wood res~ ~,op Ho1lyWOOt! ~S~ ~ ~ t, NAME OF (I/wr! tw Awyftd. /ite ~dttt W~rsM) IENGTN OF f. STIIEEt AOOIIESS NOS?ITAI ~A 6138 S• W• ZS t.fl S~. ~ STAY tN IA ' ~ A iAlly/ `"ST'7"T'°" 6138 S. i,tl. 25th St, res? „o~J NAM[ 0I ~ Fl'~~l ~1f1d11t Luf DATE J?fwA D~y y~p OCC[AfKO • «~~~j~~ George Alfred Oonaldson ~TM April 12 1964 S. 5(7f CO1011 011 MCE 7. NAI111~E0 ? MEV[R MARN~EOQ ~TE Oi ~MTN AGE Ito~ r ttrOCA i t~~ ~p,;~~ t~ ~ Y ~ 1 t. Male .white f~ewtu~•, ~~r p~ N~ W~' rrioowca~] avoncco F@b 11 1883 81 p 1~ i w 1> >0.. usu.i oceu?~TaN (ar.. ~r~[ y~o•.E te¦~ wo. K~MOOF ~vse«css o~ urousrRr ~ ~~ar+~aaaec (sr.re ~?A?sM. ew.n~) unan os .rw?r ~r~ •itA p~~. lwlqwutyra~~s/l~/i,ncw!/r~tvtf) ••^•p• Gear and Tool C Winsted CQRR. U S A 11~:' lAk ~A7NEJ1'S NA4E 1~. MOTNE4'S MAiO[N NAME . ~ ~TP~~~~~~~ ~ John 0. Donaldson Elsis Schultz IS. xw5 O[CE~SEO EY[I1 IM Y. A ARwEO iOf~CE51 ii. 50^,4LL SCCYR~TY NO. 17. IN/011 • f10NwTYw[ ' 1 r~. r. ~r alrwl l// ~w. riw w w~dw ~/rn:ed No 335-~0-3107 a~~«• 15 Smith 5t Ham ton tv. J. ~~n~r•] 1~. t~use o~ oewtrN [8.tn ~~J~ Me eaw~ ti.e/w t~). ~e). (c).I 1?REnV~IlETWECM ~ dfi~~tof /~TL OU1MWwSUUSfO~ri I • . p?~ET~Mpp[ATN su~t tl~• IMM(DNT[ CA115E (a ! f t~• a~r- ~ a1fle~t• ConC4ioaa,iJewf. OuE TO ~0~ a f tA tL• ~r~lit~ /att ~ I • • • ~ ODOC[ C~Y~t~~~• r~siat~~~ ~~iAI t~t ¦R4r- WE TO (t) ~ •1tA?• 7i 7C Itiw/ t~YK lu[. ~ Aour t- ~ ~MT IL OTIOI SKhIfIG1N~ CONqiq16 Q01(iWUfyq rp pEATM ~{Jf Np~ R[uhp Tp T~ TGyyyk pt~S~ ~q~p~fp~ Gry~ W ~Mt 1(~) . WAS ~UTOPSY t~t d~~th S _ ~ IF~tFOIUMErDq) or b~hN ' ' YES~ +~O~p ¦ akia j~~~ ACGDiNT SUICIDE MOMICIOE OESdII~E MOW WJUIIY OCCU11AE0. (EUd ~~fwt ~/h~/rry 1~ P~rt I K Pal /1 ~/Yt~ d~~p~~l- V ? ? ? tie¦ •f J p~. TuIE OF Nwr I~Lw~tl, p~. Yrr 3 l~d~. 3 IKIURY w, t ~ P. . = Nd. 1?UURY OCCUR11E0 ~t. ?U1CE OF IetJGRY u~h~r! A~we, m~ pTY, TOWN. OA IOGTWM COYNTY STATE WM~I[ AT ~ NOT N'M:~ ~ 14~./«eo+r. ~•ra, eptu uy.. ae.) WOPK AT WOAK 1~tt~nd~d th~ d~u~~~dlroan ~ to Elpri 1 1 ~ qF~~i ~nd/~~t ww ti~m ~/ir~ on t,L~f~,~ tA occurr~d~t ~ in on lA~ def~ af~f~d~bor~; ~nd to th~ b~~f of m~ knowl~d~~, 1r tA~ c~u~~~ ~t~t~d. ?11 it~~• . sl MATYR[ ~ (I~q7?te ~r 1• ?Ip. ADDR[SS Ilt. DATE SIGNEO ' ee~yl~t• ~ /9"~~ ~ !J ~ 7,? ~ ' {P ~ •ea~~~t~. ~ ~ Swc~ . p~TE 23e. tu~ME CwETERYORCaEMATOIIY ~.lp~Tqr(~yr.(~~.M~~r) (y~~~) ; 8uria~ apr 1 196L Hol wood Memo ~ardens Holl wood Fls. ~ ~.C~ 1 iei• j U Al Wqi OII'S SI R App~FU gO,/ d js• TE RECO. ~Y LpCAL pEG. 2i. REG~ST(Utll'S Sf6M RE ~ a~•.~ose ,~'.~(lLtt~cJ q~ollywood Fla ~ ~.3 / G (~L~ ~ r.~.... ~«.e~n. s....~ -ir - •rir - - - ----~"'~-r- . - . - - - ~ - - - ~ _ _ _ i ~ ~ t_. ~..r++-.-J ~ C~3TI~ ILJ COPY • • ~ ~ I her~o,,y certify the above to be a true and correct copy of the Loaal t ,.~~~'2~'h~r~ s record on fil e in the BroWUrd County Health Department at ~ _ ;~`~bs~`~~p~~dale, Florida. ; ` r~t, ~ 1 ; r . i • ~r•' , . • x ` ~ i ~arn~h~a ~~o~ Lvalid unless raised - seal of the Broward County Health ~ ; :J ~ ; ~ ,;.~-;~e~artment is aPfixed. } - - ' ~ ' : ~'ILED AND RECORDED =Z ; 3 w ~ ~ Y. ~ ~ t ~ = =:~T, LUCtE COUNTY, FLA. _ r= r,n~r v~Ptr iEO y~ ~~~:+5'' os~~ A~ - ~ . _ - ~~e~~ ,t_a 1g6~U8 J~! ~ . unty Health fficer and Local Re istrar '69 OEC 2 A~1 IQ g y~~-~--~ Q~.~;~~~, " ' =t(1: j-t~~ ~ ~i~s . ~ CLERK CIREUIT COUR~put Local Regia~rar~~~~p~ O - . _ - _ _ - - - - - - - - _ ~ ~ € .~"C~F _<,_..9.. ..~_.J. ~r.~._. .r xY- `.~4 3:~:~