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HomeMy WebLinkAbout2339 6TAT[ ao~no o~ NEALTFi CERTiFlCA E~F QE~H 2 O~'1$'7 ~t YURGU OF!VITAL RATiiT~C~ Q1 .J~ Jti fTAT[ FIL[ NO. .,~~~1 ~ee- " ~t • ~ o r1 rAen PIRTH NO. ~~-~G Ir f~,l-~G' .y~~' F L O A D A 't' RCG16TRAq•S NO. ; ru, erly i e t u t e d 1 K4C[ O~ O[ATN COOE NO. 2. YfYA~ 11[NY~NCt M.~ rw~d Aw~ fw.At.Mr Ao.6.M id... ~..,..w) ; • n d • i l 1 CWbT11 ~ _ , / l/ STATE A. C01111TT ' i Dc p1~NQ l ~ t"' ~l1 l~ l-~1~~ ~i t ~ p~f- S. QTt. TOMN. dl LOCATION • t. IS ?lA~( Qf p(ATM e. tiT11. TOwN.011 LOG?TqN , t. K ~ESiDiNCE ; f a~nent INS~OE CITr 11Y1T51 ~ 1 ~ INS~Of CITY UMtTS1 rci~. ~p resp MoQ) /"O~T /erLe res~, wop MAME OF ~ ~yy~?, ~ KIle! ddtM) ~ IENGTM Oi I. STIIEET A0011ESS / ~+OS?~TAI 011 ^ O ' / STAYf ; IA ~ U L ~ l ~ T~/1 ~ ONES i~AIIM/~~ INSTITYTIp11 ( • ~ s: NAM< OF A'?M A/i/(/~ LW DATE ~IMt~ Da~ S't~/ r~ ~~~u?u~ N',isik o°c~~~T»December 26 1963 f ~na•• w;u> Avvnes S. SFI( . ' G. COLOA OR RACE 7 MANA~EO NEVEA YA11A1ED? e OATE Oi ~IAiN ~ AGE ~tu~ li UAOCA 1 fW tAJ(11 N MS. 1N! Dirt~~11 X~.~y pw Mwn Xi.. ~ r 1 t• ~ v / YrIppWED ? dYORtE6 ~ f' a 1 n 1~ 10~. USU~I OCCUMTq~ ICi~t ti~f ~/rwl 4wt 1~. K~l/OOF WSINESS O~ {MOUSTIIY 11. NFTNK CE ( ~ft M h?tyA CN~!?~) 12- aTUti+ ot rwt cou.rrnr? t n p~ r- rr wo ~t ~l wNW e~rw i/ rdird) d U G~ U 9. ~ Cieei[ lelt ~j_ (ATNEII~S NAME N. YOTMER'S MAIDtN ME or r~ t~y~tllt~r ~ . ~ ~ iS MIAS A D(YfN U AIIYED iORCES? 16 SOCU~ SECUR~TII NO. 17. IN/OAM ~ aNATYw~ t ~ r... . ~rl.~...« ~r.. ,I l c~ ~r /i waa~., r, 'r u n e r~ 1 1{. C~Yfi 0/ O[ATN [~l[r NJ~ o~t erMt yt? Ji~e /v (AI. ~~f (t).~ IMTERV~I \ETWEEN S; ~AIIT ~ OEwTN MAS CAUSED \Y~ ~~?TN t_ d 1 ret to~ ~YME~~ Bronchopnoumonia .~~t ff1• - tAr c~r- ~•~,wa~,;~•¦,, o~c To ~e~ ~hro~:ic Pyelonephritis with Ureraia 3 months ; c n c~e rlid ~a~e .u~ ro 1 o c s 1 ~Dott «wt (i). ~ uw t~1e ralrr- ~ r e 1 s t r~ r 2 /~ia ~~~r~t l~af. ~E TO (t) .icofn T1 O ?ART U On~rw 9ewKan GOwoinoMS CoMnu~urq~G t0 Oun~ w!t Not ~[unO io rM[ f[~erw+LL pauSt Cpw~ipw Wr[N w~u~r ~(~l . w~5 ~uTO?SY neurs af- ?EIIi011MED? ter deftA v ~ ip ~ or b~fer• ~ YES? MO ~ c ~ ? ? na •w~ ~ ~ ~X~~~ ~w WUIIY OCCU11RE0 (bl~fp ~~rt ~/tRjur/ iw PMt / P~?f J! iltw Jt.) y ~ ACCIOENT SUiCIDE NpMICiOE d,.~a..- ~ ~ D D clon. Of Do~ ~ 20t T~ME Oi Hwr ~fw~f~?. M1. Ytr ~ ~ • uuu~r ? G !-s. ,1 W i ~ 2W ui1U1111 OCCU~IRED ~k. ~U1CE OF ttUU11Y (t. u M~Awf ?~wt, mJ. ~ CIT7, TpMM. O~ lOG1T IOM COUNTY STATE i ~ WMRE AT ~ NoT rrM~~[ ~ /•~•.I•d..r. r.ra. ay.. ac.) ~ ~ WORK AT WOAK ~ s 1~tt~nd~d t!w d~cv~s~d /ro~ to CeA'' r •ndl~~t w~ ~/i?~ on ~ ~ a. ~ DNtA oeeutnd ~f ~ p.n on th~ d~h ~Nt~d ~bwr. ~nd fo fM bNt ol m~ kaMrJ~d~~, /rorr~ ~A~ uu~~~ ~t~t~d. a ~il fNN . r• to 1• ~ Np++~TY~w[ ~ `1~pM~~~ p fY!y ?2A A~DItEiS j2t. p~T[ S~GAfO ~ ~ a. i.~• . C N L ~ South Florida State Hospital Dec.26,1963 ' • e e u? ~ N. ~r~ ~ p~TE I3t MYE O~ CEMETLRY OA CACMATOAr j]/. IOCATpN (Clf/. t~~'°w. a t~Y~f/) (St~fe) ' ; urw.? csva~d~ y~ ~G/~ ~ . ~ ~ I Z - L - /t G~. /~-~J/~/Lf'r ~ ~ s. ~ e i a :i c s s+c~?n, css ts p/~ ~1 ~ ~ /,t uto_ ~r ~ots~ Ii. IIEB~STiI~ 'S SU'iNATU~ ; ~ rter.I00a , / -7 ~ /~L: 'Ai LL-i ~~~I~/~~ ~ - _ - _ ~ w+.~.~r - - - - - - - ' _ ~ - ~ ~ C~3TI~'I::J CO~Y • ~ ~ I:.ereby certif;~ tne above to be a true ar.d correct cooy of tr?e ~ocal ~ p :e~istrar's record o:. file in ti~e 3rovard County :iNalth Jepartcer,t at : = ?ort :•auderdaie, ?lori~a. ~ ~ ~ . (:larniag: ::~t valid~ un:ess raised seal of the Broward ~ounty :iealth ~ ~ dp : .;~~~axt~ent is affixe3. j , _ `y ' ~ ~ u/.,~ ~ ~ - ~.~~e~ ~ ~ ~riv ~ _ , y , ~ - . " w ~ x v r- ec . ~ ~ ' ~ ~~Zr-?~p ri - ' . ' ~ry°''= ~ ' ~ ~ ~ • County iiealth Of cer a~~d Local :te~istrar ~ ° 2" _ : ~ - ; , : : _ ~ - ~ ' ru~Uy~j ' ~ ~ ~ ~ C _ . - • . ~ ~ ~ p ~ r Q - - : t ~~J-~J~ - . ~ . ' ~ 11 ry'.,, N'. :4 e ~ O V ~ . , _ • ~ ~ ~ `~j• ;`'f W • . ~ ' - f/ ~ ~ ~ ~ . . . " . ~ . ~ ~ ' ~ - Jeputy Local i~egistrar ~ ' . ; - - - - ~ ~ : - ~O~If t t~~ - . ~ ' ~ - ~ - ~ ~ . - . . ,