Loading...
HomeMy WebLinkAbout1783 ~ ~ - - - - - - - _ 1~~. ~TAft ~OARD OF MFJILTN CERTIP'ICAYE OF DEATH . ~o••• ~ ~tlRLAY O~ VITAL rr~Y~Qnc• F L O R I D J~l ~TwTi f~~~ No. i~s.i r.~- ~ . ord sA~n OIRTH NO. AEGISTRAR•S NO. ; PfOpf~lr COOE NO. 2. YSUAL IIp10[MC[(w?w~f.cw.lbut f!wn~.t.s~~ R.../.+«Wa~~/vu.:«) ! 1. ~IACC O~ O[ATN ~ •:etuNd a ST~T( A. COYNTtI aad •111 C~NTY ; e. o~.~.e B ot~ard C~' ~.~.idx Sr 3[~d ~A 1~~_ A. C1TY, TOwK.ON IOC~TqN t. ~S ~I~CE O~ OEATN t. CITr. TOWN, OR LOC~iqY t. IS QESIpChtE "~ept INSIpE C1TY UMITSI INS10E C1TY UVIIS7 ' r,i.. Fort Lsuderdale TES~ ?ap Fort Lauderdale ns ~ ~ - f. M~M[ Oi (//~N~w b~pifd. Ire it~ttl MlJrta) I. STIIEET AODRfSi ! 11pS?IT~I O~ i wsT~TUTa~ groward General lledical ~Ante 3120 S.1Y. 21at. Stre~t _ _ MAM[ O? f1~+t dlidue ~ Lut DATE MMd p~ Yea ' Y[C[ASEO c~v~ M r~~~> ~1GENIA HOP~s °~T" Nov. 13 19G8 S. SEX ~ CO:O~ OR RACE MARRIEO ? NEYEN MAllRIEO DATE Of ~~RTM 9. AGE (le ~tv~ r~~~ ~ ~EU ~vpf.12~ NK. ls~t OirtAlql .~I~.u. n.w N.... Xa. r r i t. Fema2e Wbite vnoowco5cl a~cco lia='. 9 1917 51 y 1~lwl ~ p~n;~ATqN IC~r~ tind o/ro?k [owt IOD. KtYOOF ~USIHESSOR INpNSTIIY 11. ~tRTNiLACE (Sf~f[ R/0?t~qA p4iU?~) 12. qiUEN 0~ ww1,' OOU~tRrt •1tA y~~- ~ai~~natNrat~aoti/e,«etiJr~tirrQ . •antat /1lCk 1t1t ~j_ ~ATMER S IU~ ~ I~- MOTMER~S MAIpEN NAME ~ ~~p~rrft~r 16. SOCtAI SECURIT~ /W. 17. INiORMANT ~ SIGNATYIt[ j2010 S.W. 1T4tb. Street ~ nobtainable ~ro~n Andre~s liiar~i Florida 1!. CAUf[ 0/ OEATN (Enta? onl~ o+ta caau pr?1in[ /.r 1a1. ~a1 /t1J INiE1lYAl /fTNEEN ~ua~ral - O?KET NO OE~TN ; alr~~`Or ~~RT L OE~TM W~SCAJSEO /Y: _ _ ~J Q ; W VEDUITE GUSE L•P/l.,P~VZeLX~ ~J4~•e :nst !!1• - tAt e~r- tltieat~ ~y,~fypM.p/~~y. ~ p~E TO (d) • •it0 tAe ' r?ic~ Nr~ n~t q 1• e a 1 ~Dere cae~e (i). resfstr~r X~u/ tRe rnle,. ~;E TO (c) I/ip un~r laa1. ) • 1 tAl n T3 O /IUIT 11. OiME~ SWr.n~C~U'~t ConGiqnS CO~TA:WtLrG i0 OuTM pUr MoT RtUiEO TO ME TE1tMW; pSUfE Ca.Wtbn GnrEN Yt f1utT 1(t) . NAS AUTOPSY ~ours F, ?ERfOawED~ t~t de~tA s • ~ YES~ MO? Ot 0l~O~! y, lptyp~D 1 •akiaj •n] ACC~DENT SI7IC~OE NOMICIpE OESCIIIlE MOYY ~NJURY OCCURRED (E~rrr ~st~.~ yiwjar~ tn Pat I a Pat 11 y~~n tt-) ~itposl- v ? ? ? tioa ef J~ T~wE OF Herr ~foat~, De*. }'eu DodJ. ~ uuu~r w. o s. ~ Il~. INJURY OCCURREO 20e. ~~~CE O~ ~ruu~r (e. ia e~ o~+out Aanr, 20J CITT. TO'~?N_ OR IOtATqM OOUKTY ST~TE ~ YrMtIE AT ~ MpT Y1MilE ~ 1s~r. /oN°?/. Mrarf. oQ[a A(~/.. ef..) ~ ` ~ XONK AT MORK _ ' A 21. / ~ttended th~ dec~~ssd /rom '~1 - a 6 £C . to ~ ~ 3 ~ d ~ ~nd l~at a~r ~li~~ on ~ ~ D~~rA occurred ~t ~'V en on th~ dat~ at~ted ~bore: ~nd fo th~ beat of mr knowl~d/e. /rom th~ e~usea st~ted. ar• totD~s . ~ tfGN~TYwE (p~prnNWlr) 22~ ~DDRESS ?2c. W?TESWi+EO ~ ~o.p~«< Gri.~f<<.~- h • ,Q~l~~~, /1'l,r~ 7 S ~v /6 ~'~-z' . ~t . t.l~gc ~ ~~~Y~~« 2]a. t:~ui, Utr~t~yv. 2)1 p~TE 2Jc. fUME OF CE WETERY OR CREM~170RY 23d. IOtATiON (Cit), lern. M rn~nf~) (Stde~ ~ ' RcMw+K (5prcy~l ri81_- a~c.~~,146 1L4 s.~Ce~~eT.l F~n~~A~h _ i~l ori d I. 5.;6 j~. iUhE~~I O~RECTOR 5 5~6'f~TUAE ADORES 2S D~1iE RECO. !Y LOCAL REG. Z6• R~~ ~ST,~'R'S SIGfjATU E SBaird-Case ,~'t~ /~/~C~ !~~~C-4 ~~•.'°6s ~~f. / - ~ Fort Lauderd~le . ' . ; ~ _ ~ CERTIFIED COPY~ ~ I hereby certify the above to be a true and correct_copy of i,he Local Registrar's record on file in the BroWard County Health Depar~ment at Fort Lauderdale~ Florida. (ti/arning: ~Not valid unless raised seal of the ~rouard County Health Departnent is affixed. ) y~~:ti;'~ ,1=t . i ~ ~ s~. . ' j '.~"-s" f a~" . ~ - _ _ - . \ 4 ` a ~ ~i - . ' - . - ' i ~W s ~ ~ . • . a j" - County Health ficer an~ Local Registrar ~ ~ . ; - ~ ; ,.t ~ ~ ~ ~ : ~~_.t _ • ~ -~G . '+~a J~ . / ~ , • , . ~ - . 'ei-.~t~~ ) - t ' t l • _ _ Dsputy Local Reoistrar F!LE~ r~1~7 ~ECO~DED ~'~ri~ '~OUNTY. rL:,. - ^ . 189of 3 ~ FE~1 2 ~~~1 II: 03 ~ ~ ~c~l~c-~'~ ~ ~ ~ . ~ i~; , ..S r!.~i:'r: C ,~U! : COURT BOOK~SiG PACE1179 :;\<pi E' - "j ~ t ~ _ ^t - - ~eG_~ ~ . .v ' .s . ~ ~'-~.v _y.2_ ~ _ _ . Jf~~~:Y