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HomeMy WebLinkAbout2308 . _ - - - Tn~+ s~- iTATE BOARD Of~ HFJ~LTH CERTtFICA~'E.OF DE,ATH • . ? 3, ~r eo~es • ~URCAU OF VITAL trwT~ancs . . F L O R I D A ~ sTwTe FtLE NO. 1~R~1 ?~e- • • _ . ~ . ord •p~n g~RTH HO REGISTRAR•5 NO. p rop~ r 1 y 1. ?lAC[ Oi OtATH - ~ GODE l70. Z. YSUAL RISIOENC[ ( R~w~ ~.sw~.f i.~«f. /!w~.r.iwv lnJw.s• ~l~.~...~+1 •i~lYtld ~~NTV StAT~I Orl.].d A- COYNT~ ~Qe and •111 B~Wa~ 1 ll De Olaeed~ " /1_ t~TY, TOWN.OR IOC~?TKN~ K?UCE O~ Of~ITM t. C1TY, TOWN, OR IOtATqt1 s. K RES~OEyCE ln p!~- ' IMS:OE C1TY IIwITi~ ~T y`. G~•e INi10E C~TY LivtTS~ o : - • jl~ I1 '•"•"c Ft, Lauderd~le rESO ?a0 . res~ raf~~ rst~. 1, 1urE OF i~ ~M?Kd• Y~~ ~frett sdSrs.u1 f. STREET AODRE55 , NpS?IiA~ OA ~ y ~ /t - INSTITYTION goly Cross 'r'ospital s6-~ 4n S 4• lra~,e~~~Q:~~w~T ~ j. NAM! Oi fi?H MlSd1s l.ar! OATE Afos[~ Da/ YeK ~ O[CUS[D pNss` pEATN April 2~ ~ 1909 cr.v~.. D.;~r~ FI`i:I~.L'`I P. S. 3E% 6~Q:OII O~l MCE MARRIED ~I~EVERlIANRIEO? s OATE OF ~iRTM ~ 9. 4GE ~~sr~ 1~ 1i~~DER t iE~R y~pE;=a wH. 1y~ 1~a1) !/..r4 O.a H.... x:.. r r i e• t~~~ ~n'hite ~~wEp p avoACeo JU~ 2~~ la ~ 0 7 y 1~l~f 17 1Q`. USU~I OCCIiPAT1ON (Cltt ttqQ O~KO~~ QO~t IOD. KIND Of BUSSflESSOR ~t10uSTRY 11. ~iRTMPIACE (Sfoft O?/e?tt~4 cOttn!?~) 12. pi1ZEN OC Mw?T OOU\ilil ,~:A p~r- ~l~opKy~~~i~o~~k.KrwiJ?dirdl ~ildin ~ Clevel~d,0~io U.S.A. ~ ¦antpt Ir Olatk lnk ~j_ ~ATMER'S hAl1E 11. MOTMEA'S vA10EN NArE ~~p~~rf ter ~~~~n~ .•~~$.~7 L' td~ 1' V~~ ~y1.~ ~ ~ J t . _ c. ~ i6. SOCIAI SECURITY h0. D. IMiORMAMT 3 fIGMATYRI AL6ua ~ 7 : L Uno~~:. Ele~~io_ :•:oLs L~:~ :'illw~~, +1~:. 1• CAUii Oi OIJITH (Ea,•tr onl/ ~nt tnau'y~rli~t Jn~ (~1. 1nE (f~) IrTEa14l 6c.MEEY ~ ~unteal j 1, O+~SET,A~D OEATN~ Ql~~ttOT ~~AT1. pE~TM WASCA{~SEpSY• - 1 ~ C a~ ~ ~ ` ~,~;~1 !C tNMEWATE CAYSE (c) GyY1G.~/~~. 7 C ' ~.l '~'-hsti1~' •ust fflt tA• e~r- . ~ ~ ~`y /~-JS ~O~t t 1 f f e ~ t• ~ Cuf itio~eJ. i/ ts?. pyE TO (0) _ -~La ~ t~---F-~ ~i tA tA• • ~r~id ~arr ru~ to ~ 1 e e w 1 ~bue eawe te). r~afstr~r ~~i~~ t~e rwdrr- OLE TO f,tT •itAln T~ 2 1/tw/ cerx laN. O IART 11. OThFII StGhtilUhT GOtiW '~0`d CMT7t~T~t~'ti: TO DUTN /VI NOt REtATEO Ty^ ~TNL 7Gr~Ml MSEASE COnyli~Ch GIV 4~ U1 ?1U1i I(a) . M~15 AU7pPSY ~ Aouis •t- F 11 1 ! ` 1 ?fIIFOR~IEDI ~ ~~ae d~atA ~ ~CVtr~. ~tZ, YaSC.\~i.aSn ~ V~VUr~ ~\Y ~v.1>;Cljvs.i. 11E5~ or Defot• ~~~~~~y~ j0D_ OESCNtsc NO' ~YJIRV OCCURREO (E~ftr ~~lurr J~njrr~ in Pwt f or Fs?t II eJiltnt IS-) •etln6 •^1 ~ ACUDENT SUK~DE NOwiC~OE - dla os!- ri - P ? ? ? ~ t i on e f J~ T~ME OF t/ai? SloatA, Da~, } iu € EOdJ. V INJURY ~l. O a. f ~ 20d. iM1U~Y OCCURREO 20e. IUCE OF IMJURY (t_ q., in N a~oat Mmt, TJ/ dT~. TONN, OR IOCATqN OOUNTY STATE ~ Ylr»tLE AT ~ NpT NHiIE ~ ~~ta/. xrert. o11[ee 5id~.. d..i E WO~K AT 1WJRK ~ 2~- I ~ttended th~ dec~~aedliom ` ~ ~ , to 23 ~ ~nd /~st aaw h~-~ ~lir~ on ~ ~ D~~tA occur~~d~t A m on tAs d~ts st~t~d 6ove: and to th~ be~t of mr kno~rledj~. /tom t• uuaes stated. ~ ~ 111 1 s jj,e SiGMAT R[ ` ( /~[t N fblt) ~ AODAESS 3~ei ~ ~ ,~j~. ~ ~t. DA SIGMEO •r• le ,l~~ • ' ~ ' ~o~plete i if, . . ~.~-1~~ L ~ y ~3~~5 ~ t~~~ j3a: 1~:IMA, CREr~TlO!1. j.]/) QATE 2k. y~ME OF CEHiTERY OR CRE~1ATpRY 23d. IOCATqN (Cif/, tsrn: e~ [orn!/) (~~u r itc~+o'++a lSpet~J~1 n . • ' p~w T-., ~r ~o P.osa .,ill Ce:~~e ~er Cric~~o, Ill: .3.~612 j~ 1:~4E~Al DtRc T011 S GH14.G? D ES;` 2S/~ ATE REf O~Y LOCaI REG. • Z6- REG~STRAN'S SsGNAT RE Re~.1065 ~ ~ ~ Riversi~e T:?G102'lZl I J ~ I~ q~ ~ u~ '2 ~v C/ O•" Gs~ Cnaoel s.nc. i 747 ~ ~ ~ ~ CERTIFIED COPY:' . ~ . . , ~ . - I hereby certify the_above to be a true and correct copy of the Local ~ Registrar's record on file in the Broward County Health Department at ~ Fort Lauderdale, Florida. - ~ Not valid unless raised seal of the Broward County Health ~ s'~~~~°'f ~g' ~ De artment is affi.xed. ) j`' • ~ .~,a~~~~f ' ~t"` P ~ : ~r~.~~ T ~~1~~•, . . " ~ ~ ~ :~i~ ~ll.EO AND RECORDED J, rT~ ...a ~ ~ ~`~'4'~C'~'• ~.~jS~, LUCIE COU[VTY, FL ~ _ •;t~-y.y~~~~..l~~:It:~-•, f?FCORn VE~I=IFD ~ . 1. : ~ Ci fa~~ l f ~ ~C~ Y1 4. y: • ~ . '~R',~ 4_),]~~Ji ~ ~_i~~ ~ ; S~F~:l.~~O~~IIII~~; ' 1594~5 County Health Officer and Local Re~istrar ~ =`F ioai i~s~~c~~~~;~~'i~ FEB 9 ~iH • 9 : Oq . - ~ s.~ eI ~ ~ . ~ . ~ oyc.(.~~' . c~~~ Y/~~t ":~GE_~= ~0'TFZAS . ~ 0~ ' ' h`~~~~ ~ ~~i~~~~•~~'~~a'' . CL~RK CtRCUtT COUR ~ ~ Q ~ ~'~~p" sput Local Registr a00K~U~ PAGE~~O~ ~ ~ x} - - ~ ~ _ _ ~ N~_~ s . . . _ . ~_th . ~ _ . _ . . _