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HomeMy WebLinkAbout2580 ~ n ~ ~ , " PAfi ~j~~ . RECS 4 A~ c~l~r. - - . . _ . . - - - .,~.~1011V _ tA« De- ~TATE BOARO O' MtALTH CERTIFICATE OF DEATH ~~a• •uncwu oF r~Tw~ rrwr~rr~c~ F L O S I D A h'wTS F~~c No. . ord ¦A~n BIqTH NO. RC IaTRAR•• NO. prop~riy 1. ~LwC[ OI OtATN COD! NO. L YWAL w[il~[MC[l~M.~rrr..L llt+w~.w: R.Nw..ad...i.:..:w.) ea~euted '.nd •lll couNri (;PF~lA".D 15-(177 s. STATt ~~~'.inA oouNrr ~D.--\/G^n 0• yl~t~d ~q 0. C1T~, TONN, 04 LOCATION t. K?IACE OF OEATM t. CI?Y. TOMM.OII LOCATIDN t. K RESIOEIICE •~A~11~ P.1L~ E;!1Y ~sioc c~r ~~M~rn ~n,~t.1 8AY iws~oe c~rr uMirn tii•. rES[~ Mo ? vcs ra IuME OF (J/ wN Iw ?Nptd. ~ itttd ~I!?tM) 3TREET AOOItESS ~;T~1a« AT i:kSI()t:i•!~~ 455 l~~UT~ n~IV~ 3. MwiN[ o~ FhM xNRs L~! 1. DATE l1lwti Dq Yea. iTYn:«D.~.i~ FnrD FS'1lYt{? ,~CC~!E?P1ICK ~?T~,1/~h111~Y 29 1~1~7 S. SE% 6. OOlO~ OR RACE yAR111E0 ,QJ NEYER MAl1wE0? ~if ~~IIITN A6E th /a?~ ~ u~ ~ Y~ tMDEA t~ MIlS. JYt NrWq) IIf~Y O~w Nwn Y6. r ~ i c• '~r~L~ ' t i I T~ w~oorcu O avoatco ~~~~f ~~~;F~'. 21F 1::~ 7 fi ~1•1"ir 10~. USU~IOCCUtATqNIQi~tli~1~/ralpwt toe.KU~oos~usurtssoea~ousTMV ~n~~ear.cew~ary.a.~a~t amrna.wraou~r~rr •ieh p~r- Irrl~/ n~at ywr~l~Ih~t,«twi/?dbdl ..a.~c CI"'~ `-""''.`l:~.'T i)S (=r.~~.~ r~ ~ +~T~t_ t~r-sr VI~G ~ 11aCk !nk FATMEN~S MAME 1~. MOT1~11Y MAIpEN NJtME o~ e~~~.r~s~~ ~!I LlIl~?p !-b1.".nIS~? I'"CC(}~2~':TC'; ~LI~1 '~A~'.LFSS . 1S. WAS OECEASEO EVE11 IN U. 5. ARYED FORCE51 16. SOCYIL SEtVRITI/ Iq. 17. MIpR • NOMATYR[ ~yy, I YII. M. M nwkMAl UJ w~e w w Mln d~wr:ed ~1r~4 w~ lC 1 C l;E~'S~1s~-~ Y~:S T 234 ~11 ?f~~S1~1 wW.~~q F'( ~I TT~ r~o a. ~ v Fun~ 1 1!. CAY~[ OI O~ATN ~E~la ~tK t~~Nt pt~ li~t l0). ~wI (t).j IIfTERYAL ~ETwEEN ONSET ANp OE/1TM Atr~eter ?A11TI.DE~TNMIASCAUS[DSYe ' ¦u~t fll• IMM[DIATE CAUSE t?• e~r- o~neae• Co,~uNw,.tJ.wr. ouc ro e) • r1tA t6• r~it? /Wr ? f~ ~ I • e • l ~bat r~r~t~il. r~alstr~r +~Wi~/ l?t r~Jer. ~ TO (e) Irlr/ u~ut J~If. . WtS AUTO/Slf ~ \oui ~n a f' O ?ART 11. OTK~ SIC~i1Wrt COMO~iqNS CAN11lN1RM~C TO OEAtN ~Uf IqT RW1Ep 10 TE iERM~NL OIYASE OOIOITCN_CIYEw M?dl~t I(~) ~ . ~ ~(RFp11YEDt c.r a..~h ~ resD MoL~ er b~ fer • 1~ . ~py ~~~r ottu~~o. (El~rn w~twe yMJrr~ t~ Pwt l a Pat 11 y Y~~ ?1.) ~I •~kfns •n~ ~ 11tCiDENT SUlCIDE MOMICIOE ~ . dl~pesl- v ~ ? ? tlew "ei TIkE Oi l/wr J?low1~. Dq. Yto J ~ ~ed~. ~ nuuAr m. W p. s. = 20~. I~+JUIIr OCCUII~EO 2De. KACE OF INJUIIY (t. 1~ a~wf ~we. 2DJ. M~. 7~011N.OR tOCATqII OOUNTII STATf WMILE AT ~ NpT MHRE ~ IVA.~N/. ~flttf.0~ O/t/.. tft.) MI'OIIK ' AT MORK 21. /~tt~nd~d tM d~u~a~d /rom . to a~.~ : 2~~~ 1~G7 •nd l~at w~ ti`~~Ii?~ on ~ D~~tb r~d ~t S~~ n~~ ~ m on tM dat~ ~f~t~d ~bor~; ~nd to th~ 6Nt o! aU tno~hdp, om tA~ uu~s ~t~tM: ~ ?ii sa•¦. L'~.. s~o c ~ . te 1• ~~/~n MWk) 7~6. AODRESS ?1t. D~TE S1CNE0 eo~pl~t• • "-r~'ri•L /syst..~t~~ ~`i. 7. ~l~LTi(NJ^"IF FLn". in~ n- ~ ~~~r •Etrtat~. ~ NAwEOFCfMETE111/ORCREMATORY 23t.lpCATqN(CYf.twn.a~wst/) (8W) ~eh. 1 19fi7 ?.LI"1GTnl ~vATi!Y`JAL CF`"~'Tr~' , ^ t!r n' i n~ * s.;el9 j~, fU U 011'S 5~6NATYRE AOORESS 25. DATE RECO. ~1/ IACAL UEC. RE615TRAR 51611ATYRE ~ p••.ioes P1EL.r;qlf:"!E~ FLnP.IDA ~ I HEREBY CERTIFY THE ABOVE TO BE A TRUE AND CORRECT COPY OF THE RECORD ON FILE IN THE LOCAL REGISTRAR'S OFFICE IN THE BREVARD COUNTY HEALTH DEPARTMENT. ~ (Not valid unless the seal.of the Brevard County Health De artment is affixed? ~ p ~ C...~,~-....,~....:v ~ ~ ' c JAN 311967 F~LED AND R~ECORdEO' Deputy Registrar . ~ - . LUCIE COUNTY. FLa.-- ' ~ , `"',r- Y_ COF[i ' V~RtFiED e.Y. , ~ ~.~~=Y_~~h~~~,,,,;,, 191806 ~6~,~, s~ - ~ i'°~~r,.~y~".'~~'~:~1~-,~ '70 APR 6 PM 2:02 ~ S~ , . ~ ~ . . - : . . . C • ` ?,7i' +r~'' ` F 4• :i: y ; ~JL~ ~ , ~V ~ ~ ~ v, : ? ~ _ , , -.rs; }t`.~,_~~.: fiO~E~~ ~'0; ~ RS ~'l~•' _ ~ y'~~~,.~ i~~ CLERK CIRCUIT COURT ~ ~ ~ ~ . : e . . 3~; ~ ~ ~ n ~ ~ ~:_.~~~f.; : ~ ,x '~~.~:f~ 0 R ry ~ . _ ..:ri . _ . ~ ` BOOK 183 PAGE~c~? / . - ~ , r__._ . - _ - ws:.:-~'~~