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HomeMy WebLinkAbout0632 _ ~~8 : - Statc Board of Hcalth State File 10. li _ C~RTII~ICATE OF 1~EATH ' Bumau of \ ual Siatistics FLGRIDA Registrar's ~o. ~ l. PLACk OF UEA'ili,~ , 2. USUAL IiFSID}TSGS OP DSC6ASEU: (i1 CounlY ~~,,,~''r_~.:.R~ ~i;tcict \o. Y? - O ! ~ . ~ -i~ ~ . ~ lbi i'rcci~xt Pr~i~ct \o_ ;j State „~~~''t - (Dl Countf,~. '-L'--=~- ' ; i (}1:rite name. eul nrmLerl ~ ~ (el Citr or . CitY or ~ ~ ~-'.t o ' To,.c ~ ...t 9~,^ i~ ~ / , (e1 CiV M towo . . ~~Toxn }o: , ^ (lI ouL:.la ciyr or towo 1A.iL, rrite HUil/?L) a (d) N~ene o[ hoopiUl or iq~tituti~,pf~ „ r . • . . . _ ~ ~ . . ~ UC not tn Aosrital or inrG:u[wn. w~ritr.c~ <t r.ar}~Lcr cr Jx~l:ca) i'~ jd/ Sueet ltio. ~ ti-.~ { J. t,.:~ C~'~`t~ i, y (e) Lco¢tA o! suy: In DpDit~l ot ltititutioa V~ - ilI ru~}l. Cire bcatiyol ~ fl In this tommueiqr . _r" " ~ , y i~PeciJ7 wbKhcr ye~nr, n~~n:M ut 3w1) (c) It toreign Locn. Abw bo; in U. A.? y~n~ ~eaes ~ z - r ' ' ~ ti ~ FLLL NAME OF DECEASED ~ ~ '^~_?~~~'7L.~ o u ~(~1 1t reteraq, i(b/ Sxi?: Sceu:it~„ ' ~IEDiCAL C,~i1TIFICATIOTI h j.~." oamewar /_.'7'-v \u. Y~. n~.c of De~tA: 3[oatL....~-~~`~' - Day ~ ~ C ~ i; Se~ J~_ , 6. Co:or or rae¢ ~ .i' ~ ' 1 car ~ r hoar / ? ~ liinu^ - ~ r"~ ~/`i y y. 1 ~ q'I ~~-y: . ~ ~ 21. I E.rcby ccrtity tlut I~ttcndcd im Ccccasad fro ' ~ ~ T i. Sin¢2e. martied. rldased or ditoreed lJ~' . ' . 19 ~To = ' ~t ~ 1?'"° : u~- 6(~) It '.urricd, ~ridowed or dirotu3. t+..'wand of 1or) ~ T lnr~_ ~ ~ 7 I I ' ~ - that I ia+t ww bi--=~.~li~e im t 0 G ~ site ot _ T r~- ' aad tLat ~ieath occurred oq the d~te ~nd Lour sLted wb~~e. ( Uun iou - ~ i• e IL) 11re o[ Luaband ur ~ri[e. it alire p:ars ~ ~ ; ' Imm.li;te eaux of deatL ' ~ ~,j +i T. HirtL dau o[ dcoe~sed - ~ ~ ' ~7 - r~ - _ • . ~ ~ Imo~tLl Idai) IICY) ~ * y~ j , ~ J= c~ : d. /?se: Yean ' lionti~ Dap~ ~ If :.v t~aq one.ia7 Dr.c tu . ~ ~ ~ ~ j ~ I I ~ c , ~ ~ ' ~r I kn_ mia. lluc W 1 Y " ' ~ ~ ' ' . GG G . 9. [iirth.^:~at ~-,`7J._~. _ ta,~"" _ . ~ Oih¢t awnditi~im C v ~ f ~CIL)~L~io'DOjWUqiY)~ IJ:.a:.•..L:V:c.~nCG:.LLC~1 i~ ~ 7lne:wl~ Dro~aaaq xetLie S moati,s of dc~t61 i ~ c ^ 10. CausloccuD~tioq ;.T :~y~~ . . - , , ' ~ i , 1S. Indu.try or Lusinhs, - ~ _ ' . ~ ~ l:n:~r f.ndic~~: ~ of o7rzailoas L'.^._triae~ ~ 12. \~me ~ - " - . t::e cause b cr.:~;: d:st:. r. IGive d~ie o( o,k•r tic:.) i ~ , :3. liirtnPlace _ ,F r__ 'I ~ " ta1~_.d be - ~ i i~_' ~ ~ ot au:ousY ehs~Fed sta- .c ~ 1S. 'Sdaidea n~me . . . ~ tiatwi:f. ~ ~ .o ° 13. BirU~ptae~ ~ . ,~3. I( deat6 ~cu due W etternal uusea, fiI1 in t1r [dlowing: L~ ' 1~. lOtO[QyOf'~ $~W/Y[f ' /y - " . 3 , ~ - la1 Ace:deat. ~uieide, Lomieide {ayeeill) - - ~ iG (ai-.iJ1rW _ - , rJ ~ ! Ib) Dau of oecurrean ~ ie) where d;3 iujury oecor2 - - - - , 17. Iiuriai, erem~tioa or remo?v! - , .ICitrorwwa) lCouatrl lSUtey l~ (~l Date - v 17 tbJ i,Lec (d) Di3 ia~~t~ wxur io or ~boat hwne. on farw, in indu+uial D1RCe. i~ t, .~~iblie ~ ls. Funcr~l Dimtnri Si¢naWrc ~ ~ ~ V~aut i. ~S;~.ci[~ trpe o( Dlace~ 16 Addroa '~7 • / ' Wh~le ~t workS ~e) 2iean~ of ini~~7 . ~ V. 8. No. ~ 19. Fikd . ~ 19 - - ~ 23. Sirnature - -j ~ ~ ~ Jd. D. ' ~ - LuaI R.~s:~L-ar ~ (a) Addresr~ ; ~ - t ~ yau Sacaed ~ -i ~+kroby asrrfry rnls ro b. . m,s .nd ao~nct mpy of rH~e Loa.l _ . f'~;'~ Rspistr~rs reoord ort fit~ in th~ St. Luc1~ Ccunty Neatth Deparh 't' f~~ (9 ~r, + m~nt ~t FoA Piarce. Fbrld~. ~ ~ f (1Maminp: Not valid unleu raised senl of the St. Lucls ° Ep~*~ 't Counry H~afth O~partment is affixed.) - •:'r k'~3~ :z ~ ~~ll~•; ,~I : , " • ,j. ~ ~t . • fi~~i a~ .r, ,l-,~ - N. D. MIIIER, M. D. , Lj+~~ r~_,~,,'~~•~'T' t '~rws~ yty!•- ~?j'.') y~ i ' ~ • : ~ CO~Ki~f f'IC2~tti ~iCOf ~e ~XiCQ~ QIQtilf~f ~~~'~!~'Z - •=WtSf FILED AND RECORO~Q,,~~ -~~~r :~~s , ~ 5T. LUC ~ E C Q UN-TY. ~4~{; ~!i . ~ , ~'~:CQRr; VER1='~ ~ .R,;•;?. Daw ~ Deputy t~ocal Repi:rra ~~~f i~;~._3~l ~ f~ ~`'1 • ` , ~ 'TO SEP 22 PM 3 : 21 ~ ' ~ . ' ~ BOGK 1U~ F~Gf s R~G~R i'OtTitAS ~ 32 CLERK CIRCUIT COURT a' ~ ~ , - ~ 3~~