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HomeMy WebLinkAbout1958 t F!LEU .r,ND ~~CORDED ~~~,,,`~,~'p ' l:`C~~ ''^UtiTY, FL: - ~ ' ~ , :-•r.t~ JOHN H, YATES ^ ATTORNEY AT lAW ~SV~~t/ CUTLER RIOGE PROFESSIONAL BUILDING ~7~ F~g y ~~1 ` I 10700 CARIBBEAN BOULEVARO 1 J •--'~/~C74``"c~-`_ MIAM1. FLORIDA 33157 i? . . • • r ~l Ci j _ ~!_-~tz~ r:~:r~~~T rni_~pT iTAT[ BOARD OF M[ALT11 CERTIFICATE OF DEATH . BUREwU OF YITAL fTATIfTIC• F L O S I D A sTA7E FILE NO. - 6iRTH NO 16TRAR S NO 1/IACt Oi pEATM GOOE NO. Z. YtYAI R[NO[NC[li~1w~/K~Nl~~e! !!~iui~h~.M rJ.wMl~~• o. cou~Tr groward 6! • STATEi' iNRIDA n. cauNT BRI~WARD D. C~TV. TOrtN.ON LOtATqN t. IS VLIICE Oi OEATM t. CITY. TOWM.ON LOCATqN t. ~5 RESiDfWCE Pompano Beach INStL+E GTY LIYITSI p0~{p?~~O p~.A/~v Ih~ipE CITY LIMi:~: YES U Iq ~ r 17r Ml\ Or~M~rII YCS ? d. NA~E OF no! iw ?wyifd, /ist atrut aUnu) f S7REET ADDAE55 • N~:~7~T~ 2011 S. E.18th St. 2011 S. E. 1~tth St. 3 NAM[ OF Fiir~ VidQ![ Lu/ ~ GATE RlontA Du~ !'es? °;y~~`~;~~, DIANTAA ~?~RVILLE TODD o~TH December 17, 1969 5 SE7C 6 tO:OR ON RACE ~ YARNIEO ~pt MEVER MARNIED ?~~TE OF 61frTM 9 1~6F i!R ftW1 ~ UtiDER f YFlul Ut~pE.t 2~ N6. F`Ed~IAIT WHITE Oct. 1~ 1922 'f;7 ~w•?~ w..w n... H.,,.. v,,. nnowco ~ dVORCED Ipe. USUAL pC:CUYATqw I Cis~ ti~d o/rwk Isnt t~ KINDOF ~USINESSOA IkOUSTNY 11. NRTNPL~CE (Jiolt o? /orty~ c0unh/) 12 CIi1ZEJ1 OF NN~t OOUYiR~e . Ir,iso ~wou o/~rortn~q hk. ~s~s t~.rrud) Qidri hoIDB 1,0 IS18PlC~ Ti. Y. House Wife ~ , U.S.A. 13. FATNEfi~S MAYE 1~ MOTMEp'S YAIDEN hAYE Albert A. Somerville Tnmia Rappelye ~6 SOCUL SECURtTY NO. I7. pli0 • t1aMATYlE A[6tp G'nobtainable Col. Milliam L. Todd 2011 S.E. 18th St. Pompano Bsach, Florida 10. CAUfi Oi OCATN (Fals~ o~l/ ~tt cWe pn f~~t (~l. (D). a~d (tl.j INTERYAI 6ETWEEN , ?~RT ~ ~ MMEW?uTE~GU$E Gunshot Wound of Head _ . - ~ ~ ~T~ C:a/ttwti• 7/~A1. DUE TO (D) ! r?uR /ore r.•a~ to ` ~Dosa caur ial. - - ~ ~f~hw/ !4 natti- QtiE TO (~1----- ~ - ~ - lliny ~au~~ lwl. l O ~ART 11 pi1~A SIGA6iCAl(i CQfiqTpllS Cp(i~Jf111G Tp OEITN ~IJT IpT REtA7E0 TO TNE TERY{N~L OlSEASE COIGiTqil GIYEM 1N PYIT 1(4) . WAS AUTOPSY F PERFOttMEDt V ~ YES ~ NO ? 20a- ~ ~ID DESCRI![ 11p~ t1U~RT OCCURRED (Ent~~ Adrre oJ~wjer~ in Pat 1 a P~rt Il oJLsot t1.) ACt10ENT SUK~DE HOhtIC10E o ~ o~ ~ D Self-Inflicted i ~ 20c TiME OF !lonr Moa~~. Dsy. Yem - - - ~ W 6:~'~pr +~eC.17,196 ~ 2Od. INJURr OCC~RRED 20[ FLACE Oi iNJURY (t. In M~-'ro4! AOrru. 20J CITY. TO1NM, OR IOCATqN COUNTY STATE WORK AT ~ AT ORK f ~ ~r f~do!~. rttl. t~its AII/.. tl:-) ~esic~ence Pom ano Beach Broward Florida 21 ! ~sNSc ued r~ - _ • - ~nd /~st s~w ~on 1~y~~_~_ eer cuned ~t _ ~JV a• _ m on the date st~ted ~6ore, ~nd to the bnt o/ m~ knovled/e. /rom rhs uwsa al~rsd ~ V~ ((K~~n or !U![ 22', ~ fODRE55 ZZC. DATE SIGNED ~ Medical Examiner ~ Fort La.uderdale, Fla. ec.17, 1969 2.~ ~L CREK~t 3~ D4TE Z3t h~VE O~ CEwETERY OR CREr~TORY 23i LOCAT~C+N ~CYr. (o~n, or coan(~) (Slclt. `"°"~".•D` Dec. i9~ ~96 BroWard Crematorium Ft. La.uderdale Florida Cremation • j ?{ERAI NEC R S SIGNATLR ~ c . ~iend~bfi Funeral Sv~z C4Ti ni'u 8~ lOC4L P.EG 25 A~ ~STR~ R~S SIGNATORE . h ~ ~ = ~ Pom ano ° ch, FZa. ~ zC. , I ~ ~q~ R %~%~t-d~ o~~~d.~ ~iJ - - - - - - - tt+ ~!~~~'s~~l'EFIED COPY - J _;wr _ . - ~8•d.~j~~/~ -3~ . f HEREBY CERT1 , .~~YF, ~I~'~B~~~1'RUE ANO CORRECT COPY OF THE ORIGINAL REEORD ON F1~~9. _ E.A~I'` fJjF-~.~(}7AL STATISTICS OF THE STATE OF FLORIDA. ~ DEPARTMENT ~ - ./l~(kj1'~TIVE SERVICES. DIVISION OF HEALTH AT JACKSONVILL ~ ~ "i-~ ~ ~V - . s =~a (NOT VALID UNL~; ~~A~ ~F_FLOrtIDA. DEPARTMEHT OF MEALTH AND REHAe1LiTATIVE BERVICEB. DIYISt~~ . . ' + ~ _ i~~ ! ~ : ~ ~ ~ ~ ~.ry - -T~=~ qirn,c i ~ ~ • • ~ ' ~ \/i~.K~ ~ ~ ,.-o - ~ ' ~ ,~f ~ ~e ~ cMa?. w~[wu or virw~ srwnmcs '~'Sl E~J _~~~~'t~ ~ ) ,~J~? I-a _r~ v V ~ 0 ;:3 _.I~I:~Ii~i:! 1\11~, ~TATt KOIiT R: Diw[Ct~iw. D t~l l ~ ~ ~ N[ALTM ~ O[~A11TM[MT 0/ N[ALTN ANO A[M1?~ILI7ATIY[ KRYIC[i BOOK~~~ PAGE~~54 ~