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HomeMy WebLinkAbout1191 i ~ ~ - - _ . CERTIFICATE,OF DEATH ' F L O R I D A "T~T~ F~~c Ho. ' BSRT~^NO. RE618TRAR_a NO. , " i ~ ~ I. PlJ1CE OF DEATH Goo[ no. ; 2. USUA~. RESI ENCE tw'~w~.aoe..au•.n ~riw~uu..-...~e.e..wt... p oe COUNiY % /w ! ~i STATE COUHIY 7 trrl~' ?'.~'~M,~+~. ( le - l 0'3 ~i ~ 'ti- " < ,/f, !L i ~ b. CITY lu Mu1M wepesa u~tt~, ~rtu ittsaL? c. LEN6Ty OF jE c. COI R ltt a~wd~ wr~x•u u.tu. .r+u s~aal.i OR ~'i/ ! ~j . ST 7(L tWa alan) • r ' towa • r • J =-t,E c t~ ~ ~ ~J ~I Town ~ . < ,i_-1_ t 2_. d. FUtt NAl1E OF 11 rt t~ You~t ~r wutrN~ stn ~tnK ~w K tawmJ d. S7REET tu nnL sa• 1~u~1 ~ H051lTAL OR ~ y~ S ADDRESS - / INSTlMIOI~ _l~"c f 1t~~~!-~tf tM..ta£ ,r Z • ~ / J~ ' ~ 3. NAME OF ? t!'[tst) j~ /A~Y~~ n , a(i.ut? r~ a. oFTE (Yostll_ (D~s) '(Yea*1 ~ DECEASED % rj . t t( I•( C/t• i J I ( er Aiwt ~ c ( - . ~.i ~ DEATH ~ n ~ ~ ~ 5. SD( 1. CO~OI O~ tAGi l. MARRIfO~ NEYER lAA~l1ED, ~ OATE OF tItTH t. A6E ~h ~ ~r u~~~ ~ r~~~ .:r ~~n~ u.~~ ~ , ~ , ! WED, OiYO~CiO ~ye.~ui1 ~ ~ _ ~ ruua~s> ~twr U.», uw. ~ xr. a Er , c c~- 1t~ ~ c c n~ t- I, - I rl~ ;Ja. USUAI OCCU!'ATION~O~n 11d ~t wes KIND OF tUStNESS OR IN• 11. 11RTH?LAGE iaut~ s t~?p o~rs? II. CITI2EN Oi WHA7 ,fw~ larios srt ~i weu~t ufa ~w u nu~) - CUST~Y ) "7'~/t +INZAYI r . ~ , : c-t~-.. ~ft-~c fGtt c ~-Rl t c ~ ~t. t,. , ~ ~ r ..L,. C _ t1.i . ~ V . Il. FATHEt'S tlAME f' t~ 4fOTHER'S,I~/AIDEN NA!/E ~ ~ /~.t .~t~ ~i ~~--!t,.• 1 i ~-CJ f.%,.;7 fL.-tJC.-L_/ ~ I5. WAS DECEASED YER IN U. S.ARIAED FORGESI 1~. SOCIAL SECURITY 17. INFORMANT'S 516NATU E ^ y :1 ~a. ew a~ u~w~1 sit~r. ~iti r ~ d~wf( ) / NO. ( f" . t. t~ a/ ~ t t: r I..~f-7~x~ ~ : t ~ ! ' ~t a T1 :~b~ 0 - C C` ! ADDRESS .,l.j - J' • ~ ~ i t~. CAUSE OF OFJ?TN U MDDICAL CERTIFICATION • ~NTqYAI ~iTMt~li Enter oay au naw L DISE/1SE OR CONDIi(ON t f/T~ r oMSrr wwn o~wn~ ~ ? rer Gnt tor CI~ECTIY LEADIN6 TO DEATH`~~ l~J; A- t<.-~ ~r I t' t- ~ 1 ; and (e) , ~ . IWTECFDFNT CJIUSES f . . . . A •ilw ~r w~t w~ss DUE TO ( t^- • 't ! cr.. wot. H~+~/. Y..iit eow~;tiewti U awr. o~~*a • r,ael~ s~ lleurt l~i7s?~. riw te tJ~ s0sw eaw f~s/ ~ut. . a,thrwia, ~tw. Jt +arr~ a/ ~ ~'~~If'*Y os"« ~K- t;u d;.ew, iyr,r, DUE TO c) cua~ri:aties r?i~?~~,OTHEtS16NIFiCANTCONDITIONS '~6~~ ~G' COwiitiow~ eowtribrtiso t~ tA~ destA brt wet nLf~d b tk~ l:xes~ w towditiow ca.viw dratk. Ifa. DA7E OF O~ERA- 110. ?IAJOR FtNDIN65 OF O?ERATION ~]0. AUTO?SY1 j TION ' ~ ?c~ ~ Mo ? :l'rae~si~1 (toWt7) ilb. fIACE OF INJU~If (.,r., tn.r •bwt ; 21a (GtTY OR TOWN (COUNTY~ (S1ATf) • Il~. AGCiDEMT M~. t~e~, t~et~cs. n.«a. oaW eUC..ca) ~ 7! e+rai. .:.u fcclc.~Li •UIC{D[ lld. iI1~AE p4rsf (~si ,ITMr) ~Wv1 11~. INJUlY OCCUtIEO r I~ . HOW DID lt~IJUR OCC1i0.1 OF *MIL[~i ROTIIIMII[ ~ IWUtr ~ ~o~i ? ~r*o~c ? ~ u. 1 hereby us~i/y [hal I a`t~teqnded tlu deceascd /rom / n-/'~ lg'~ , to i9 cko~ 1 la+l row !he dcccased ; alitr on~D , J9~( nnd lhal dFath oecvrred at ~~~~n., from lAr. ~auses and on thc dnle stafed abnt~c. 9 ~3a. 5lGN/1TURE r . (Dtgree or tiste) 13b. ~DDRESS ]Ic. DATE SI6NED ' % ~ f~ ~ . ~~l,i..t~.t ~C : ' ' . r"' ~ r ` c.r ~ ~ /n ~f- yr ~ :<a, t U R 1 A L, GlFl1A-~24?. DATE 24c 1NAME OF CEME7ERY OA C0.FMATORY ' Nd. LOGATION tCit~, to~va, or ewatl) ~(8t~t~) ;oH ee?eo~ w~s~ / O _ ~ ! - J"~ .t ~ ~ . - i , ,1 ^ , f f ?tf°,~. ~ ~ ~ t' A-t~_ b~ . . ' ~:L t ~ ,t , , . . . , , ~ . " . , .e .,c , DATE REC'D tY LOCAI RFGISTRA!'S S16NATURE 25., fi1NERAt D)~EC70~'S S16NATURE ADO4ESS i i ? ~ Lr~,l9, /9v`~$'~ /'~"~.c~ tU. h.~~.~ - ;;:.-~-~ft, Cu. '~,~t,U ~f~~.21 ce~ _ o~..~~ ~ . t • ~ FIlEO ANp RF~~R~ED ~ i +~~bY a~rtify fhit to b~ • trw and .•6T.~OCE~ Ppj R~a ~ m~int~m'n For~~n~on ft~brid~. th~ S1. Luci~, CourM~,~Hyss~hh p~rt RE ORO~vFR~ifCEO QOURT~~ . ~ . • ~11Vunirq: Not valid unl~s rats~d s~al of tM St. Lu~cl~ ~c' l q ~ ca,n4? ~+..,th o~p.,,,,~.n, Fs .ff~x.d., S8 PN' -r,~' . ~ . i , N. D. MILLER. M. D. ~s~ ~ - . GourW iiwlth Offiow d~ , . ,I - Local Rplstr~t : - ~f. _ . , , ~ ; ~ ' ~ ~ ` , ~lY.~~ . _ _ ~ rr , ' + ' : ~ r ~}~{~N _ ~ • , : i ~ 4 ~ / , ~ ~ '1+t . F~~+ , ~ , ~ ' ,i?~ fa ; 1 aoac195 ~cE1189 ~ ~ ~ ~ ~ ~ , i 1 ~ K a ' ~.-.r~p_