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HomeMy WebLinkAbout2158 ~ ST-1Z,408 ~ ~ ~ f~_~ -CERTI~FlD COPY 205~U1 W< HER~BY CERTFY TNE COPY REPROOUClO QlIOW TO BE A TRUE AND CORR~CT COPY OF TNE ORIGINAI RECORD ON FILE IN TN6 9UREAU OF VITAL STATISTK~ OF TNE ~ sTATE OF FLORIOA. OErARTMENT OF HEAI.TH AND RENABIUTATIVE SERVICES. 01VISION OF HEALTH AT -j11~(;~(SW'1V~LLE. FLORIOA. lNOT VALID 1jU1~ , O~ THE STAT[ OF FLORIDA. OEYARTYENT OF NEAITH ?NC A(NA~ILITATIV[ i[RVICi[i`~bf~ ~~?1 AFFIXED.1 • ~ ~t:, ~j'a> • ~ t / 1~ w ~ i ~f~ C ~ CN~[/. lUAEAU Oi YIT~L iMT1ir1C~ • V~QV 7 ± ~ • w , ~T ~~I ' L J . • . ~ ~ I r • 7 • i ~ ~ ~ / ~ ~ ~ 1~ ~ :+'h~`~ . t -~j ~ t~ ~ ! , lTAT[ A[GIS111AR; O~R(t10R. D1YIQpN b1 ~ V T H ~ ~-~I N[ALTN ~ O[rAIITYtMT OI MtALTM AND 1~.. - . . : \C - ~ IIINA~~IITATiYt i[I~YIC[f ~ ~1 ~ ~ti,, ~g= I~, ~ O ~ > y~ _ - - - RATt ~ CERTIFICATE OF DEATH (5•0 5 6 7 6 7 ~YR[AU OR 'I~+~ fTATt FIL[ lt0.~.~_~--- FL08IDA .;8 i~ SIRTH NO RE~i1~TRAR•f NO. 1!?ACt Oi OtATN COD E NO. 2_ UWAL R[NO[Mtt 1~'w.. ~«wd t.«t 1•..~e.s~na qd~ w/~ C01iMTY SUTE A COUbTt ~uv~ I 26-083 ~loi•id~ ' e. tm. to~. ae iouTan t. K~L4CE OF OEAT1 C1TY. TOWp. 011 LOCATION • t:5 RESIOEMCE ~NS,oc tm ur~rst ~ws~oc cm ur~rn Jacks^rn•i res~ ~oQ i~cks~ ' i 1~ r.ur~~ ~ res[~ Mol]~ t, tUwE OF ~ J( a~t i~ ~NyKd, Mt Ksut sl~rts~l ~ LENGIM Of t. ST~EET AOOIIESS : j t Oh A FlRY~ NOS?~T~L OR STAY ~M IA INSTITU110MD~`~.~„c:'p -'a~ - 1^. .i~ rE5? MO~ 3 ~u?~ oI iLK Ni,i/te LYt pATE Xwt~ Dq Ym Kcusso . ~ 0 1 ~ ~ J t~:urr~v Schneider ~,?iM D c, o< S St1( ~ 6 CO1011 OR RACE ~ NAl1~~E0 ~ hEYER MARq1E0? S~~ ~/1NTN 9?GE 1/w ~ttl! ~•~~E1~ 1~W {pOaH 1~ IsM Sv:~d~fi .if~l~ as~ Bwv~ Y~a. , 1-.c l~' MIOpYfED ~ dYORCED tll]1` 1 ~ C(! r n 10~. USU~I OCCUMTqM (Qik t~a/ o/ rwL /otr IOD KIMDOF ~US~MESSOR IN045TNY 11. qNTNPIACE ($?~ft M/i~tyA tw~tr~l 12 Qllgll Oi nMT C017wi~+n ~ trrlwp ~oN N rerti~y h~r. e~n i/ rdad) ila:.r.er S t•:~: C.~. Ciril ~~r~~ic _c~ "'ez-- 'erk ?"SA t3. iATNE11 S hAME 1~ MQTN(R S MAIDEN K~ME IS. RAS OECE115E0 EvE11 ~i~ U S_ AltMEO FORCES? t6 SOt~~I SECUR~T11 MO. 17 1N/ORtlA ~ f1YNAT1IA[ ~~a t 1'r. r. ~r s~lrwi w. I~w w~ iYw ?~wrt ' r:o I _ A/b{ai :lil~ F.lti•i~ ..r. <<~~5.-~.• _A~ . f~LEC~ 1yg F~COR0~0 ET. LUCt~ CO!lNT~ F[~. , PG~~E~ FpiTp~s , r~ cpM C~~~UIT COURj n ; THIS SECTION CONTAINS RfCOF~ YEr~iF1E0.~~1'-' ! CONFI~TIAL MEDICAL CERTIFICATIO~I 11~ ~ ~~9 I~F1 ~~f ~ 2U560i : x a ~ ~ a ~ 's ~ ~ wvnn . ~ 2t I ~tt~lri~e 16sS eei•sad /~om - - - . to •nd la~t ~aw A~m ~br~ on _ _ ~ DNtA occu~rW ~t ; m oa th~ d~N ~t~td ~Dor~, ~nd to fA~ Mat ot m~ Ano~rl~p, from tA~ uus~a ~tabQ ~ 4~T~~ (De/~n ar CYk' 2t~ AODI1E55 ?Tt. D~TE SIGIIED ~ ~ Z_`~- _ sa~ 20~3 Fiverside ~ve. J~a,Fla. c.1,1965 23c 8~,weAt. CREr4~qti j~ry p~'E Z3r N~rE O~ CEyE7ERr OII tREM~TOa~ 23(- IpC~Tq~ ,(Y~. ~orw. e? (3~u~ ~ Rtw~u ~ ~pres.ry, ~ ..aG. _ -1 . ' 2! ~ 5 S~Gw~ ' ~ cT.. C~ 'lt" _ . ~ - ~ ~y ' l 8 MTE IIECO ~1I LOC~I REG 26. ~f6KTItA11 S S1GMA ^on f J~~ - ' ~...1 "O:T~ / ~ ~ ~i ~7~~ ~ ~ ~4~~ }e r« ~ e-~ - ~ 190 2154 - ao~~K ti .ry ~ s.. _ - ~o~~~.~n.._..__..~.. s.~ - ~