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CERTIf'ZCJRTE OF DEATH s~at~ t~t~ No
a~aTti No. wtiw ~w. Nw Custodian's Na
l. NJWE Or a. lfirM) l?. (Itlddb) a(Lu1) OgTt ( ) (Da~) wr)
DECEASED
lT1D~ or Pri~1) ~~i~ ~111e2' DLATH ~I'C~! a3~ l~
ll~e~ d D~atk • ~ac~ WMn d~ew~d ~~d. U i~Hlrfiw e~e~ ?d~e~ ~
! e ~ ;
co~.ti Coffee tieorgia ~~7 Coffee ;
- - u.id a ~ c~ti t~.w t.ai+a ;
Ci es ~w ~ lfe ? I ElAY (i~ llis pl~c~) C~ti ~ O Yw IH O fTAY (i~ Ws plae~) +
~ DougLas T..,. Ticholls ~
cm t
Naa~ ol Hwy. ~~~d ~OSpi~l !~15 Z'lY'~ • EtrMl Addrw~ er ~ ~j
e. laatitutios L R D. aad 3mc Nw • lr~
S. SEx i~~1lCE ~ R E(S~au er lo~~ias eou~t+T1 'CO1ZE11 ~ WHAT S. r Me~ es ~ la~ IR 1011AL =1 DAtE
N i V ~ Cotfee Co., tls. I 1.7 S.A. ,rK ~5 o I ca~ew?~nox aI 3-2b-60
-~.-n~ra or a u. ,.u. tr vx~ta ~ Yun Q o~~ ~ xas. x~wa caanaY ccitr T••••~ cc.r.e,~ ta~.~.~
t.tl eicleaq) w.e~e. caT. xotirs ~u..
0 8 6 I ~ I lror~sest (#rove 1lcholL Colfee Oa. ;
io. ~ xevta iwa~a o !L M~+ri~d u 1N'~dew~d Gih NaM el SP~~ mawwsa•s s~arenrsc i ucn~ ro. ;
vinnowcnurunim
o~ ~ I DeliL 8aith Chas. M. 3ias I 1139
i vauu corsnoN cci.. wa svsn~tas ot ~ncwi ~
ao.. a~.+.a ..a ..~~.v m.. n..~.a~ nmumY :
~1~.rsinQ OMa lfa1~ ~ Si~s Funeral Yw~e
was aec ~ nr v. s. ~ roac~t ~~secuaist Ko. T~ cu?r~'s iwesa~es
IYN. ae. w a~luowr~) ~(p T~s. yin wu er d+tN d Mc~ic~) I
D~ugLs, ~ieorgia
no ~
1 J. FATt{Eit's NAta
sr Yli~ah Tsnaer Son
14. MO E11 IUIItE 1. 1MAIf!'S JlDD1FaE
~a D~vis Douglsa. (ieortia - - -
22. CAUEE DEl1lt! (Eat~r eatT ow uus~ p~r lis~ fer (b). and (e).1 aiFaVllL 1~TMIELt/ DO 1~0! NRfiL I!( !!Q3 E~ACE
PAlT 1. DFJItN WJ1s CAUSED sT: I O AlID DEJITH l. ~
A~OfEDtAlE CAUSL (a) ~0~1i~,~~llii~ ~
z 2. ~3. I~.
0
F- Co~d;tiees. 8 aa~.1 DfJE IO (b)_
V which oa~~ ~ NI S. ~R
aDeh eaaw )
w statip t6~ ~ud~s-1
l~isq uw lasf. ) DUE TO (e)-
~ PAIT p. O~L~r siyni5ea~~ eosditioas eontaib~tbq to d~atb bat ~et n~abd 1~ H~ t~rai~al diMas~ eendi~ oi~w fa ?art !(a) ~ b. AUlOTSYT
~ Yw ? lle O
IT
~ 2~. ACCIDF~IT C7 tLACE iMUBY (~.p.. ii er alow 11QlTSY OCC011ED =7. I~~nl~ n~tifT tLa1 I~H~d~d t?~ d~ew~d
~ SIIICIDL heM. t~ra. I~elorT. w~N. 1Mei1~ at tNwk ?
~ xo~acws o°~" °'a4.. .k.~ r.e wr:i. u rv.~ - ~0 3-23 i~ - ~r.~ i,..~ a«..«a
lC~n Da ~w~~ ~C.O~~ O f (IteatL) (Da7) (YNr) (How) ~h Ow - a1d ~i~ `
I~Y 5. 30 A ero. ~r. ~.o... .ae sa u. a.e. ~f.aa .s.... ~
d~a1Y oeco+r~d a~ ' • e, 3
' 2R SIGtU1'fIJ1L ~ D~vr« x?!U~
HOW DID IN?lisY OCCti~i: r.... . .
iER .,r Roy L. Jahnson, I~l. D. ~
i
ZS. DAlE lE-~- . ~ SIGIIAlOEE ADD~ DATE SiGtt~ £
3
28- ~:•"c•-.-~: rts cw~rson ~ nouglas, Qeorgia ~ 3-23-60
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k 'v~.~ f.'y~`~'` ~S~r` y. - , CERTIFIED COPY R
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S E A L (Q1din++Y) (HNltb Oic~r)
~ , ~ ~nxs.l~ Record Custodiaa
~ 20584H
~ flLED AND RECORDEO
~ ST.lUC1E COUNTY FLA.
~ Il06ER PO?TaAS ~ ,
~ CIERR ~~RCUIt COURT
UECOA~ VERiF~EO ~
~ ~ii 323eM•t~
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