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HomeMy WebLinkAbout0713 2~2~58 212858 " FIlEO ANQ (tECOii p ~ ST.l1lCIE CO{fM~ll ~~1. fIOCEF PO~TR~}~ CLERK CIRCUIT GOURT ; RECORD VERIFIEO,,,.~~~ : i ~ 16 3 ~e PM'~ I TAl s 0~- iTATt sonwo o. Nw.~,+ CEf2TlFl~ATE OF DEATH _.,G~ I~,~1 r~e- ~YRGU OF VITAL fTATISTIG~ fTATt FJLi N0. t s FLORIDA ord ~4~a j r~va~~l' BIRTN NO. R GtiTRAR'f RO e s~ e u t td ~~~u~E O/ ~t/1TM GODC NO. 2. ViYAL R[W O[lltt (~4n M~..t W//:.r.ww.~: t~.r..r N/.. ~d.,u.:.a aw~ •111 ~~TM a. STATE t01tNTP D• yl~e~1 ~ - !n !~i- CIT/. TOMM.011 IOCATqN t. K?U~CE O~ Of~ZM t. C~TY. TO~f~.011 IOC~T~0r1 t_ ~S RfS~OCNCE ¦~q~~l 1l15:DE p7Y l{ytTS~ IMSIOE CITY UMITSt f11~. 1rES~ ~q• 1RS? Mp~ N~VE Oi (!J Mf b ~Mrid. /it ~trtd NIrtW) IEwGTM pi I_ S7R(ET ADOII(SS ~ r~~Tti ~ STAY w 1? ~T,T~T~ p L ~ ~ ~ .~o ~ ~ w?..~ o~ ~..r v~~ wTC x..u o.r re.? ~p «~j'~) RU ELL G Ih~RTI Y °tATM I~+tAY 2 1 . SCX ~ OOIOR 011 IU~CE 7. NwnRiEO ~ NEYCII ~ulU1tE0 [j • OATE Of WTM ~6E 1~ ~q?1 ~ YWM 1 tW yt iaf. W 1MIOOYLD ? pYORCEU ~~q1 YwW ~M Mwn Xh, yl~twt~ • C~i z ~88b 10~. YSI~L OtCWAT1pN (Gi~t ti~/ Nr~rt ~t 1~. Ktw00i ~USWESS OR M~ONSt~Y 11. ttwTWti/tCC (yldt ~r hrtye pNah~) 1 plltp pi t1Mi Cp{pI~TT .l c a p• r- twi.~ qnt y.n.luu hk. eu+ i/.eri.et~ ~1"~k`1.~ A"~ UILDI~G W~ST VT~GZNIA JSA 17_ fATNEJI-S lIA1Mf 1~. MOT~/(R'S MA~OEI~ MArE i s~~~~r~~~? N•Afi 1T E.~.A EUR'1iS IS tiIAS DECf~SEO E1fEA ~M ~ S. ?RYEB AD71CC51 !6 SOCtAI SECURRY NO. 17 {M/OR i NiMATLw[ p G• ~az,tln ~Y .r.rafywl UJ~.M.~w{W~dwrwrl rirrJ• [l~ F WFJ 2' --0 _g7p Au.~u FT PI ~ FLA. FY1~1 f~ I 1~. CAYK KATN =Ewft~ Mli pe taf~t ptr 6v /~v 101. aa( (t).I IwTERY~I iETMEEM d 1 t t 6 f ~AAT t OEATM rAS CAYStD ~Y~ wp ~ATM •~~t f11• IMY[OUTE C~YSE W > > ~ (3N, (~E . F ce. e.r- "r"•`• i~•~,• w,c ro t~~ ~_alized ArtcrlQSClerosis •ftp t\• r4t~ /~es •u~ b ~ 1 e e• 1 ~Dwt c~a~e r~sfstr~r ~ d~fiw/ [4 ~a~[._ D1iE TO f~h/ t~ur l~+t. - \ Ov • f' ~ IMT M. OTK71 SKwIfrGllrf Cq~O~Tq~6 CprtlpqlflY'. 70 0[wtw 7RR 1~07 MJ1SiD i0 TM[ ifria~y p6tAS[ ('qkpllpw Cly[w w/MT 1(~) . V AS AUTqSr K lE1tfQRMEOT tK d~at! V . • 1P~ YET ? NO pJ of O~f~?• ~ ~ ,h ~~tf~ a~ 2GD. OESC11tK NOtU W WY OCC~NRED (ELft~ wdart ~/M~/t?/ iA P~rt I K PWf /I ~/ifta s ~ ~ ACCIO(Mi SYK~DE MOwrCICE t~p~~f- u ? ? ? lo• •f ~ ZOc T~rE Oi flw. Xw~. M~, Y~~r ~~d ~ wu~r G 1- W = ZOI au~Rr occuR~c~ 20r. ruce oc ,xiwr r._ e..neat a.sr. 7D/ urr. mwM. at tnurpw oouwTr ST~TE MfM:I[ AT ~ tipT M~wtE ~ /vw.I~M1. ~rtd. o0[t[ 011~.. H[_) 1rORK IT IWAK 27. !~tt~ndod tA~ d~e~aNd liom . to •nd !ut s~.r A m ~li~~ on ~V eP " W~th oecun~d ~e tn on fA~ d~t~ ~t~td ~6or~: ~nd ro fM ANt d m~ 4no~rHOf~. liom fM uuN~ ~t~t~d. ?11 lt~~• ~ ~Q~yTYR[ •t• i• 1• ( l k l~~~~?~ Y4i 1 7 L AOOIIC55 Ilt. DATESIf.~[O ce~Pl~t• k ~ C~. Pierce '~a• S~ ~L3t? •eerr~t~. 23~ Mau. Cw[rar+Ow. 230 DdTf 2Jr 1NYE OF CEwET[Rr On UC~~T011r 23/. WU1T+Ow IGY~. fwrs. eK~h) (3~ftl IIf~OrILL (JOr[~1 pT~~ z' ~.'~S~'!'E3Y F:. PIE,T~CE FIARIUA 1. s. f e 11 j! i1iMtNAI DME OA S 5:4lIA YIIE ( . • jS p11TE 11SC0. ~r tAC11l AEG. AEGKTRAR'S S~Gq~T4RE RI• •IP66 ^:iC~ rI.A. t 'S-5-64 Anr?a Lec Genison d.r. ~ her~b~r c~rt+fy tha to b~ • t?u~ and oorrect oopy at the local , Re~~:N.r~ noord on f1k in th~ St. ta,ci~ Counry F1e.hfi t)epset~ . : : nrM ~t Fwt PfKa, Fbrida. , • .-~-~"f_~ .S, % (Watnlnp: Not vaiid unl~u nlsed sea) of the St. Lud~ ~ ~ County i;sstih D~p~artm~nt (s aff'+xed.) . + - ~ P+~ ~ ' - , ; N. D. MILLER, M. D. ~ - County H~alth Offiar d~ Loal it~lstru . D~vry Loc~l R~cist?a? ~ ~ ; , ~ ~ t- ~ ~ R ~94 713 ~ _ ~ - - _ - - _ - ~ - z _ ~a