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HomeMy WebLinkAbout0857 iTATE BOARD oF Mew~TM 'CERTIFICATE OF DEATH l~~..(~17j C~ f~ , - BUREAU pF VITAL rr~T~~r,c. . F L O R I D A gTATE FILE NO. _ - i B~~R~H NO FEGISTRAR~S t~0. ~ r 2 YSUAI REf10[NCt ~~+.[.ew.dt....1 l~.ui,e.• N~..I.wnM~..~~/.o....wi . ?U1C[ Q? p[~TN ~COC_ NO. z 7?:.~T~ ~ A=~ a ST4!E ~ Cr,U~-. i90~~_ ~ . - = ~ ~ ~ _ _ - ~ . - . . ~ L~TY. TOA~ '_i LM4?.ON - -r- • aL~:e ::f~!H l. ~tTY, i0Y1N.OR l(K~' ^!y~- _ IS RESIDENCF ti5'~f L•w~TfS~ ~NS~Df C1TY L~M!-I~TS~ v, Z'~ _ . :.)r: ~ rES ~ NC t~ ~ ~ i i~l ~ rl _ _ ~ Y{S 1K~ :J . t' ~ 1~~P+TOF JP !l,.w ~a ~a.pYal, p¢t c~rH aJ~•rw _EMuTN Oi ~ d STREET ADDIIFSS ' ON A fARM~ . ~Tar ,ti t ~~5T~7UTK~N -:-:r .~ii U.°:- - _ - _ - ~Qf 4 ~ ~ES? - _ ~ z? _ --1._- 3 NAM[ Of _ Flr~t tl:s::r - - - - La~t------ • DATE ~1wtA Lay }'tar e[custo oc - ~r~«w„~~. ~ :i~ ~ ' ~ rULi~:si,. DEAiH ~(~G. ? L 1 4 DATE OF BIR7M 9 AGE (/A ~lC~J K VR°.:R 1 TEM ~Np(R N WK S SEY 6 CJICP OR RACE ~~~Rt.r~ ~NE.ES M4NP'E~ V - la~t Dvf~1~~) .V..~4 D.r~ Hwn X:+. :°r:~ai e Cl l t@ rnocwc~ ? ~voncEO - P.' l.:i ~ o V4C 4StlAL OCCU~~'~ON tQ~a tfnlo/irak /ot~ 1ai K~!{OOi {IiS~NE55CR IMWSTNY il BiR~MPLACE ( Va[t M fe~eyw counlr~) 1Z CITUE`I OF wM~T ~1l.YTRlII larh/ ~oM e'rati:/ l~p. ~rew if rdird~ . 1 1` r.r~ r~ ~r, ~J~~ut..:~: iieJ L1. v 1'_l. t3. F~TMER~S N~ME It wOTHEN"5 YAiOEN ~urE - ~ 1. S~:er ~z eth ti IS. ~~15 OECEASED EVER IM U. 5. ARMED ~ORCES~ K SOCUL SE[i:11~TY rq. 17. IN?ORM • NONATYR[ f'~~y~ ~ ~ Y~. r. ~ olv... Il/ M. M~ M~/ ~ Irr1 d u~~n• ' ~l {Y ._i~ y ~ A[4et! - It. C~YSi ~1 C~ATN ~F}~tt~ aJ/ ~~t c~rae y0 l~ta Iw lU. e~! 1r5.; , InTERYAL ~E'T1NfEN IART 1 OEATM NAS CAUSEO ~Y~ " ~T ~A~ ~ > IYYEOIAiE tAUSE 4~ yti_!"'! I ~ , k ~ ' Coalitiw~.i/~/. OuE To (01 _~n~~~iL'Q~'` - - ~ elid /m ru~ to - ~ ~Dwr rssar l~). ~fdky At rwltr- OI~E TO (c) ~ ' ~ 1/iy r~a~e fa~l. - , - ?Af1T N ar~t swwr~uwr toNaTn~s ~wc ro ocan~ ~tr raT ttcuho m r~ hrtr ~~jy?~7p ~?1~~1j~ • NAS AUTO/SY LU ~ " - ' • • ?ERiORMEOt ~T~ - C TCS? MO~J F p~ ~ 20D otstp~ec ~ow auv~r otc~A~o (E~to wderr o/hjw~ ia /'ut 1 a~J![~~r~.) p ACCIDEMT wK~oc ~oMK~oc ~9 5a € u ? ? ? TIYE Oi Hoar M~M. L~ef. Yeo ~7 ~ • - . INJURY w•- - - ~ - - ~ - - . i O . _ ~~ilt'~ . _ . . . _ - o y. - = 2Q/ INJUIIII OCCURREO ~ IOe /LACE OF i~JVRr (r. 0., n a a~oel ~our. 1Df C~TY. TOIfM. O~ LOC~TqN COUNT~ STATE ¦N4E A? ^ NOT WMIIE /arw, h~tM/. s'rtd. ~~ct ~10 . d[. . . ~ : ~ J . F; ~ 7011K u AT M1011K ~ . . ~ . ~ 2~ I~tNnded th~ d~ce~Nd hom _ Z-. to _ n •ndl~at w~ ~~lir~ on ~ De~th occurr~d ~t m o~: rhe d~N at~ted ~Lo+~: ~nd to rha b~st of en~ Rno~l~d~~. /rom fd~ uuNS ~t~td. aa NtNATYK (lM~n kl 22~ ADDR 22t. OATE SKNEO ' b ~u . ~ ' , cvr. ~ 23~ pulp?l. qEraiq~. j3p 23c Na~E Oi Cf ~ETER~ OR CREM~tOqY 23/ IOUTiOt1 f(Y/. lorn• s~ toe~~!/) ~SY~ft) . ~[rOru ~Sptn//~ ~ n=~T:ovni _ - ~ ' ~ s~ C~.*:.e e Pierce Fl ori :a ~ z~ iyNE dR[~'011` S~SfG1UT _ 2S pATC RECO B~ LGC~L ItEG ~pEG~STRAR'S SiGq~TLRf Er ~ _ _ r~.e: ~e . _ ~r _ , ; , . . 1 ~ ' t ,c~t•' f •~'vi.~ +,y.:~r.. ~ ` , ''~!'J . . 7 - ' l - . _ ~ - ~ : ~CERTtFtE~-C~PY-- - _ _ _ ~ ~ ~ 1 HEREBY~ CERTIFY THE ABOVE TO BE A TRUE AND CORRECT COPY OF THE ORIGINAL ~ RECORD .-0N ~ILE 1F1' THE~ ~UREAU OF VITAI. STATISTICS OF THE •STATE OF FLORIDA. ~ DEPART'M~MT OF HE~LTH -AND RF~IABILITATIVE SERVICES. DtVISiON O~ HEALTH AT ~ JACKSQNVIL~E. FLORIDA.. t , . ~ =y i NOT VAiSO ;t7NGl8?. ~N'"E~.i;ALf.OF TME frTATE OF FLORIDA, DEPARTMENT Of MEALTH AND REHABIL~TATIVE iERVICES DIV19/ON O/',~S4TIl IS AFFIXED.? ~ : ~ - ~~--t-f - , T CHIEi. 6UREAU OF V11AL fTATIfTIC! ~ ~ FEB 2 019Tp ~'r n ~ ~ W;,~'o.~`', 54~~~ fTATE REGIST AR D~REC7b11. D ~t10 O ~~l~I MEALTM ~ D[?~RTMENT O~ NEALTN AMD ~Y' O ~ 183 85?. ~NA~ILITATIV[ f[IIY~GES ~ d00K ~ ~ - - - j . _ _ 5+.= _ . . . . , . ,.....~':"k~,