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HomeMy WebLinkAbout2011 1935 ~ 2 ' ~ ~ ~ ~ ~ ~ ta~~ Dt- ~TATE Bowrso oF H~?~,,, CERTIFICATE OF DEATH co~es a ~UREAU OF YITAL B7~T16T7C8 STI?TE FILE NO. ''sa1 FLORIDA ~ •rd sAen BIRTH NO. REGISTRAR•S NO. yroperlr •tftcted PV?Cf OF D[ATH . GUDE t~0. 2. USUAI RF+19[NC[(WA..rJxw.dl:r.i I!iVtA~:~N~ RYJMN~~~~~~y~y~) •nd •lll f. CG~MTY 3'AiE ti A. COUNTt Broward c Florida St. Lucie !w pOt- D. CIT1/. 7JN'N, OR LOCATIOti t. IS KACE O~ OEATII t. CITII, TOV.'?I, OR IOCATqN t. IS Ili;~pi~~( •aefpt INSIpf CITY 11Y1T51 INSIOE CI1Y 11Y1fS1 r~l•. ~ Holl wood .ESQ Ko0 Ft. Pierce „ESO d~~r~i.ort i~ ~fpitol, ~isc ~[rttl a!Qn~a) I_ STpEET ADORESS INSTITYTIOr1 Doctors' Hospital Holl oo RT#4 Box 107 - Midway Road 3. MAMt Of f7?~! ~ Mi3Elr Larf 1. DATE Mo~tl Dq Yt-- ~ ot«,?~fo I OwIItS o~TM November 13, 1969 c~na.• MA..RGERY D. S. SE% E Cp:OR OR RACf 7. yARR1ED ~J NFYER 71AARIEO? 8~ DATE Oi B~ATM 9. AGE (Iq ~tN1 ~ ~?Wi~ 1~Wt ~~.~a H?~i5. fsK dir lLs1) l~fs+~4 D~N Mw'n afu.. r ~ i c. Fema le Wh 1.tE Mnooweo ~ avaecco FE:b 24 ~ 1918 5;1 pl•fsi~ IOC.USI'AIOCCUO~TION(GKtkt11Q0~1FCTttpA[ to~.K~~ea-~usinessoaivousrAr 11.OIRTNPLACE(y?n(eas~vtyator~lr~) 12_dtut.ros~nutoott~Ttrr ~1tA y~r- /rri~~ wut ejrorti~p G/t. «en ~J?etirt~) ~~p~p~ Housev~ife O~vn ~iome Penn. V.S.A. ~ IlaCt 1Rk ~j, FAiNEA'S MAV~ ~ 1 1!. MOTNEII'S MAIDEt1 1tAME ~ er ~ t~p•*rfter ~ 16. SOCIAL SE:URITY h0. 1~_ INFO.:HAHY~t itGe1ATYRi A~p~i~ _ nobtainable B Phone Theodore S. Ow~rs Rt#4 Box 107 Mid~~ay Rd. Ft. Pierce •un~ral fs. C1lYff Ol D~ATM (6~ttr or.l~ oat c~a+a ptr li. /nr (o?. tD)_ a~A ;cl.j FILED AND ~~rtcAi~i e_T~ctn ~1~~CtOi ~ARTlOEATNWASGUSEDlY: fust fll• IMMEOIATE CAUSE ~t~~ ~ IE COUNTY~ FLA. ~ETµ00EATH tse eer- ~t;'. ' ' - ` ~.~QU~~..~~.r.: ~ To ~b~ 935`~'2 .1 ee eAe r~i~~ ~ere ng eo ( 1 e e a 1 aDcu ca+au (a). ''1 ( ~r~aistrar Ke[in~ tAr QR/[?- ~A~ ' 9 ~M 'O ~ l~i~~ teutr 1aal. Ot;E TO (c) il fi ev ~ •lsAfn 72 = l~ou?s af- ~ IAAT 11. OtNER S+GtuF~[ahi ~~~iqRS CM'TR~S:lfLV~,. i0 DGTM WT tt'vi REU7F0 TO i~tE TErtyeuLL ptSE1SE Cpt~1TqN ~~iqR~t~f . WAS AU70PSY ~ fERFORNE~+ ttr ds~t4 ~ or se~ore t.~._ ~T~as V rES? r+o~ «w~~V~ 2DD. OESCN~BE HOW INIURY OCCURAED (E j~ p~~ l /0/4tn1 le.) ~ ¦attna sn~ ~ ACCIOEKT $t~1GDE MOVSCIL~E '~~~(°(~(R~lr ~e d~sposi- W ~ ? ? tion ot ~ Dod~. ~ IOc T~?eE Os Hoyr Jlonti, nar. 2'eer . INIUAY it_ O D• W ~ 20.t. INJURY OCC~qREO 20c. ?l~C( pF ~hJURV (t. p.. ~n or c'qr[ ~OAtt. 2% GTY, TOWN. OR IOGlT10N Cp1;NT~ STATE " reN~lf AT ~ h~T WN~IE ~ /a~. /acfor/. s!rert. olite A'd~., rtr.) 1NJRK AT WpqX Z~- l~trended the dece~sed /rom ~0 11 13 69 and l~at aaw•~°~ ~/ir~ on ~ ~ D~~tA occur~ed ~t ~~m on the d~te sr~ted ~bore; ~nd to tA~ dsat o! mr knowl~drs, f~om fh~ eaua~i at~t~d. •11 lte~s ~e ftGMAi"'tF ` are to De (~i~« e. tDlA 21~. ADOAESS 1It, O~TE S~GNED ; co~ylete ~ /+"li~-J • (~:sL~ ~i. /j /~Cj ' •ee r~t : 21: r:~~L UEMaiqh, jly p~TE 2]r NAME U~ CEMETERY OR CRENATOAY i 7C RE t ~ r~/ 1 23d. LOCATIOM (CifP. [etcA. N t~~t4!/1 (Strlri i ~`rfa~ 11/17/69 Hollywood~Memo Gdns. Hollywood,Fla. v.9. e . 2: . o~we•T,a swn~T~ -,fT'-= . ~~~7~ O ~ :S O~TE NECO. /r lOC4L REG. 26. REGISTRA4 5 S~GMATURE L~'t ter.lY63 f"''!-'fi.^~l+/ •~+`f=JJ~~I74~0~~~~~a • C 7Q.1-~.C ~ ~ 3~ _ . . : sJ'' ~ ~ J ~ _ w ~ ~ CERTIFIED COPY: ~ ~ ; ~ ~ I hereby certify the above to be a true and correct copy of the Local 8egistrar's record on f£le in the Broward County Health Department at _ ; Fort Lauderdale, Florida: ' ~ ~ . , (Yarning: ,R~t':valid unless raised seal of the Bro•aard County Health ~ ~,p~tment is affixed. ) ~~~~`;`4;,s~~._,, . - 1s : . ` . f, . i w : . ~ ` . j~ y~•:.'rrc' ~ ' , ' ~ y ~ ;.F; Q ~ ~ . , ~ ~ r~. ~ t~ "~i''~,,: . ~ r 1t ` . a..' ~ , ~ w ~ , t/ . a o,:~: County :iealtn Q icer and Local Registrar ; s - . ~:-w.v;btyi~r.i~i.~ ~ . ' ~ ;~o~~,,; ~f:.!. w~ .';-..~x-- , .a::._ ,~;cZ~ , , S!'. r't a~f'+. . : O~' - - . ~ sn y p~rC ~ 'y-,,;~ . hf f#y~~'•• a ~ Wl~11184 f/WC2~o~ - '~~t` ~ 7 ~ 3"~ . _ . . . - - G _ Deputy Local Registrar