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HomeMy WebLinkAbout2137 . _ . - - - - } . ~-t°~' CERTIFIED COPY ~ ' ~ . . ~ , ~ WE NERE9Y CERTFIf THE COP1? REPRODUCE~ BEI~W TO 9E A TRUE ANO CORR<CT ' COP1f OF TME ORIGINAL RECORO ON FiLE iN TNE BUREAU ~OF VITAt sTATlST1C8 Of THt STATE OF irtOR10A, CEPARTMENt Of HEAI.TM AND REHABILITATIVE SERVICES. OIVI~tON OF HEALTN AT JACKSONVII.IE. FLORIDA. ~ lMOT VALIp U _~i THE 1EAl OR TN[ sTATt OF iLOR10A. ~EF'AI~TMENT OF MCALTN AND w[NA~IL.ITATtYE tqVKt{, OIY ` _~LTM If AiiU[Cp.l ~ ~ ' ~ ~ ~ ~ ~O ? , ~r~ ~r, L 2 3 1910 R Y17AL ~TATi~tIC! ~ . 4 , 3 I ~ ~~ax~ ~~w~i1.h'1~ ~~.a' ~ ~~Q~~' * • . ~ ~ ~ ~ sTwr= ~4imeww: aw~crow. av~aaw M . W ~ + t~ cJ " wsw~rN - oc?~urMCwr or ~waTM wo ~ ~ . • R[NA~IU7AT111t ~[RYtC[~ ' i~..: ~ t~ • _ • j~ - - _ - ~ - - - - iTAT~•, - , ' ~ ; CERTIFICATE OF DEATH ~ .un ~ • ~ ^ FLOSIDA nwTR Fa= ~ ~ ~'Yhf . ,~w.~ Q s~RT N.'J ti REGI~TRAR•~ NO. Z'J ~ r~:~t[ N . 'f Qj~~NO. 2. YfYAL 11[S1otMC[iR~w.~w..d6~.t ll.w.~.r.w: Ie..~..wN...wr...) c fC~~7Y Le~~-~_lI' ~~i.^ ' STATE U. COI:NTt . ~`'bZ6 Florida Lee ` i+'Y. T01111.OR IOCAtqll ' ~S K~CE Oi OEATN t. CITY. TOMIII.OII LOC~TION . t. IS RESICE~ICE ~1~ 11e5t~E CITY ItMITS1 IMS~OE C~~1/ UYi'S~ + . Fort ers ~8 ,.~p Fort h ers ~St~ ~G . 0 ~~rE OF ~IJMf i~ ~Myihl. fre ~tteN ~!l?p11 ~ LEMGTM OF ~ STREET ADORESS ~ . - ON A Ff11M ~ STAY ql lA ~ ~ ~~.S-~T~T,~ 1 2 Brookhill Dr. 6 mos. 1 62 Brookhill Dr: ~L ~o~ ~ 3~ou?nt o~ f1hN ~i/Y~ Lre ' 1. o??TE Xwr~ Dr~ Y~a n~ Albertine Moss S arks ~?TM Nov. 6 1962 S 5£s ~ QOIOR OR RKt 7. WUItEO ? 11ErE11 MMIII[0 • 011TE OF ttl1TN ! AGE (Iw i UM0011 tTM M~OE1 i1 MS. / t~~) YwtV Dy~ Bwn Yn.. ~'e ^'.al e i~ltllt e moo.EO C~ a~c~co Ms , 1892 ~ 1 J~ ..5~~ al OOCtiI~TqN IO~M Rt~! ~j eM! Ip! 100 1(~Ip pF ~yStME55 pR tpptJSTpY 11. ~IRTMrIACE (Slott rr fKtf/it C~t~tr1) 1. Qt1~1'!1 C~ ~IMT pWN'1bT ~ ?i*I ~e M ~M wn il ydird) - ~ousexi~e ~ome Grand nap~ds, Mich. IISA ~ ~ ~ J fATNER 5 IMME ' I~. YOTME~'S MIUOEII NAME ( u~knoxn ) Whi ttier. - ( unkno~rn ) ..a occcnseo evc~ u. s~wco ~o~ccr ~s socu~ sccuMTV w. ~w s asw«we - 'f- w--.......? u1..c«.....~w..r...:.~ . . . ho None w.a~„ Fort ers a. • e e.YS~ K~tnrn (~rue. wt~..~ cswe yr~ c:~e ce?...t ~ ~wrcnv~ ~erwccr ?s~T . oun~ ~ws uusfo w• • a~saT uw oun. wMCS~?~ c~usc ca ~a• ou[ To (8) if~it_~~1~l.L~ ~~~I' ' ~ .`e~..''°' ~«"7 ~ ? . ""~y `"r"" ocrt ro ~a r ~ ~ = t/ey n.r l.r . O /ART N. OII~ SIG~iiC4ff 001~It1d6 ~OMI~lt1i TO OE11N W~ 110T Nf1AtED 10 iNE tEp1OMl OIYASE COIp1T4N filYE11 M/MT t(V .~A AL'TOISY K~FORMEDt `i~- rES ? AO ~ r. !06 OESC~~~E ~~O~r MtlunY oCCt?RREO. (E~t~? ~edert yiays/ L~ PMt /~r Put l! yYew 11) ~ RCG~OEMt 54K30E MOMKI.'7E ~ a o 0 ~ Ek .*~r[ os Nws x~tR. L~s. Siw u ~w~Rr ~ a. n a- ~ 2W +~uu*~ OcC~~Rio mr. R~tE aF u~wnr (r. u n ~lw~t Mrr. i01 dTr. Tow~. o~ ~otATqM ooc~mr Sr~TE iMKEAT ~ IbT~MIIE ~ Ip~.I~/.l~tlf.~~p[~y..dt.) _ . ~10aK ~T ~0lK _ Z~ I~et~nd~dtMd~ewa~dl~om ~/_(~„=~F ~ .to ~o ~ dlwta~n~~li?~on ~~-3~~p . DweA oee~rr~/~t 2 8. ~ on tM A~t~ af~t~d ~Ao?r, ~nd to tM bat o! m~ knowl~dp. lrors~ th~ caura ~t~t~d. ' _ ~ ~ j~M (,DqrK K tlNt~ 2Z~ AOORISS Ilt. OATE 516NED ' North Fort ers, j''la. ~ 11/6/62 L3a MtY. (~itq[ L~ OI1TE • Zk. lt~YE O~ CEMETE1111 011 C~EMATOQY ~ 2~/. LOCATI011 (G~f~. [Mw. M tMAt/) I$~f) . ~ . R[~Oli~l!$ . ~ . ~e*n s 11 62 ~ill Crest MemoM al ~ r~.Aa ,~~~•t r:o~•ce, ~l."s. Z4 ~ ~ a SS a. 0l1TE KGO. ~ IOCA~ RE6. GKTRAR S SK,M RE - , N. ers, r~le. 7- b 2 A~f'~aat" ~ ~ ~ o ~ . r ~ - p r~"~i ~o ~~v . c~r•, ~mZ ' . n v ~AC ~C O --i --1 ~ W ~'1 Z ~ n m ~1~~ ~ CN • • ~ Q~ ~ ~ . . _ ; ,r ~~1 ~ ~a~~+2" c+a3 a4.+~ b Y"-':T..''; ?-'~~T W. ~'~-~~s`vk~F..~.`