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HomeMy WebLinkAbout2200 C~a...i~t. ; POLK COUNTY HEALTH DEPARTMErIT ~,7eo~ ~ w~~uww r. M~~~. .iw.. w.o. ` • 14//GP3o~70 a~caro~ ~ ~ ~ - ~.Ci~ . . . JF ~EA 1 H ' ~).~...~1.u.~d •~i ~::...,i~ .~u~t ~~.•~~..~.~{~1.?liv~ ~erv~-~~ O:ATf. F.I ?iU ' - i i,.~.~.~~~ .~i ut ~i ~u ~ L v ? l~ t1 . . ~ . ~ .~~1i 1A r.... w.n•~n~n~s f/i' .Ia.. ~ 11~i •J ~J ~ I.-;.•..1\[N~ INK - ...•.rr ;,~r, r~.~. `:lt~~W-hA~~t n~ft r.oo.~ ~~fl .Klt ~ATL U~ u:wP~~ • • . kc `.?~~S:J[ Wt 1 ` . • I T ~ , ? J ) 1 ~iSfi~CflOul ~ i J~C~~~ • ~ . ~ - " 1 ~j1 - ~ ~~~V~~_.V\I._~ ~ ~~li~.l~ ~ V~ ..J: [~CE ~~~w. •~n~:•.. u.e~~w, wGE-~•i~ ~•~w~• ~ .t.~ ~.-.a~. ~ . pw~NRTH ~+w,.. s.., .COld+i~ CM tnwin ~ ~r~u..~ un.a.. ~~~~~f~t-roi Ta..~J .ouu ~ ~ ~ ~~.~ll.V ~S~ ~7 ~u ~ ~ '~•~i?1~l ~Va ir~L r Urr, rON•N OR :OCAT~ON pf pfATH ~ w~~ai c~~ .~+~+a ~NOS?~TM O~ OinEN NSf1TU1YON-~t.u~! wr :rn~= .•o ~w.~~~ . t~'~ v~ a.. n s o~ ..o ~ _ -'-ti; ;r- ~ T ^ j;~l: :;d c~a ~ _ ar.d G^n~r~? i;~;: ;1': : . _ _ - STATf J~ ~~~iH ~u ..o~ ~-s • . w•~eiC111ZFN pF wW1T COUNTtII ~Mwr.:1cJ. rr:v~~t-w.n,tatEO. SWY~~'~.G :K~U;E •••~a~ ~ cowm~ 1~ ` ,w~Dpv+ED.G~:'C4tCEO~fntrn ~ L a.. _L~. .t_.~ ~11¢flw:! 1\~~~: t~~a ?SLV V • S• tl• !1 .1rl~iC.~ 'll 1 _ 1 ~ 1/~~- _ ' ~c~ ~:~~ci n. Si:U2,:Y NJMldta ~ 1~SUAl OCCUlAT1ON ~c.•t awo a wu oa+e owwc .osi a'[~D pF 2~Sw:SS O~ +++J~:'•r :::.,uea 1 "u""'o un. eviti n ~e~~aeo ~ i 4 ~•.s•~.o'~0... awt ` ~ n ~ ' V ~ n lCi L ~ ~i• ;e uaae ~t 26(1-~6"J~lb'b~' ~t7~ t~OSt.b17 L'.:~~~0_11... j.t ~ ?S ~ , G: i. • • tES~JEr.iE-St~tE ; COUNT~ iGT11, TOvMN, OR IOCAi~O?+ c~~ ~'+~~1 ST~EtT ~?.L riU.~.~ct f ~ ~ ~ ~v~u.. re~ w wr ~~a`'liT'~C~1 Pf?SCO ik Z~ (~:'rh'~~_S iue 2•vr? 3~': ~.Sfi~~, L~n^ : Mtr~ER-wu~E ~nas .~oai ~•s. MOTME~-MADfN HM~E •:n~ ..~oai wr l ' • ~.~r' , ~ 1 ~ `°r"~ ~s U21.~•Oi~c" ~i~ ti~1.._--~'.O:'.^_: f INfORlNANT-NAME MAA1NCi A,O~ESS ~s~u~r w~.r.~. »o., ar. w ro~~, u.n. :r~ ~ ::rs. ~:clcn :•i.^.Clusky 301 Cindy Lanc Zephy: nil~s, Florida I hui ....o.~~.r~ ~~r..... O oEwn~ w~5 CwusEO ~r: ~E?+tEr Ornr WrE uusE ~[t i~E fOr I~L pL ~ kN Mn.~~M OMHt ~~N N~1f ~ ~~.yy ..rwn cws~ . ~ 1? G.(~,~,~,~„~~• ~ O ! ` `~L ~ • • , . - ~ ~ co»a~no+s. • ~ ....c.. •,si ro 1~? TA~ 1 IrrlO~~Tf C~V!/ /01~ ~y( t0. O~ ~1 ~ CO~~fOYtK~ M' . ? 5~~~~~G ~w! V~?!4 ~ a~»c c.vsi ~ E ~ , ?c~ ~ lAiT 11 OTHE~y S~Gr.JK~yt COtiW7~ON5: cw.anaw co-.•4~V~~f. p . v ..or u~.rEO w cwu oM~ ?ur ~ w~ , AUjOISY ~if rE5 +e.r .~..o~..ci co ~ / , ~ ) ~ ` . ~.~s o• ~•o~ ~ yo~~~a ~w xu~r~r.»o uwa~ mt ~ ~ i: / . ~ p~ ol.~w d''~M~ Y '-l'-`'~.~.~~{p LC.'L.~ 1\O ~~n t0 d~ ceoo'. wC'~aE~s. S:t C, OR ~DATE wJU ~rONrw, 0~~, *t.n ~r~OUR jMOw IN/Ntr OCCUtlED ~tMl~ wTVM O~ uuwr ~w r.n ~ w r~r u, m~ ~~r C~ .v:'~~ ~Ji. Ot uWEtEW~hED p~OC ~ ~Sm~hr) I j ~ ~ a O~ W ~ ::a i~ ~ 7!c ~y i tp1. a ca ~ N s1vJUiY AT WORK Iu~Cf OF e~~Wt .i .w.i. ~•r~, srrn. ~.nw~. ~ lOCwnOn ~ inui o~ ~.r.o. ..o., un o~ ~or.., u~u ~ [7 V ~ i?K.n r~f O~ •~O ~ W~K~ MOG., ~K. 1]IIC~ 1 • ~ a i d=~~~+ ;u 'r~h o~o~~ A : Jt ~O ~ G:C':fitAT1OH- rW~fM o~~ tl~~ ~ rOr~w~ Nr elu : u~O Wt S~w wr/wa~ ~~M ON Wo/oo r.~~ v~e~ nN~ DE~TH OCC~3uED •r n.~ nKl. O~ tw! . J WQ rnrsK..~: ra.~w ~r nu f~oo~ uia~w•rw. E~wu~~ a..i- *o ~.e Ks~ h- JO ..^t.oio r..t TO 1 ~1 ao~ rr ~.o`..eoW. ov' ~'"M VW ~ tt~ o~:~.s!a..o. - S - ~IL~ iJt~ ~ 7 r L ~ ~tla ~ ~ ~ I ~ ~tu .7i-~ ~i. T7h Z2 i~~ 'of..tc.uu~a~fu~rs ~ CE;~~F~C~'~Ow-+M:JK~t Exw~rw~fi OR COtOt+ER: on ~w uan w uy wo,N w ae.w j Tq MClotMt wy ~~pr~p;w(10 OW e~....~.r.N, o~ ~,e wo. •w~~w rw wv~ua.r~o... ~.u w~+ae+. ••w*M e.. .e.~ wu. ~~e•rw ott~~uo OM at o~r1 u~O OYt t0 M UYSI~fI it~R~. M.~12~. I 7'~ ~ SU /TM~ ~ CERLF~ER-wti+f .nre oe n...n : S~GB:ATu oeeue w nn~ ~DwTE SK.hE ~~o~- . w•,•w~ N. !S 't''^~ ~!k ~~J J . r/' ~ ~u e n ' f ~ MAKIhG AJ^uRc55-'f8iv.[Q u~ee+ o~ ~ r.o. ~.o. t~n w TovM sr.n _ / / ~ ~ 77; /..i~ i~ ,C il /c:. .l .~i ~~T /~%~C• .r~ < ra. l ~t : s <t ~ ? F~C~ / t i:.w~Al, CRcMAT~pN, itfMOVAI KFMETE4Y OR CBEMAiO~Y-NACME ~IOCATION Gn W~OrM f~~?a ~ 1 1?tUn ~ - ' ^ S r~ - ~ i2« l.'^~~'A'~ ~:~~'~`r.C~ ~ itk. 4~tih~~ nil~$ f Fi~i i~~ Ci : c. u l: ~ ~ c~ '.~wTE ~ ro~rw, o.r, ~tu ~ iUNERAI MWwf-IVAMf ANJ ~OD~FSS ~ aruer w e.r.o. wo., un M ro•vN, ~i~n. [u ~ ~ - - - J~:~. 3, ~971 Lair~s r^u„^r^~ - 403-St,h S*, .Zc~i;vr;~jl]_s. ='i~. ~ - a0 i2 it,niLN G~RERO~t-SiGlv/~)~ ~FG STiAR-S~vh:'L3E • Q...~\ JAiE tt<tirt0 ~044 i14~1'cwi _ nev.1970 7s•`•1tA..::L"~.'LC.~C. G~_ t4~ ~ J?w 5 F] ~r ~'~4 1 ~ ~ ne:eby certify the ab~ve to be a true and c~rrect copy of the Local Registrar's rec~rd on ~ :'i le in the 0°~ice of- the DNISION OF YTTAL STATISTICS, at the POLK County Health Department E~ ~ ~'.~'IIv ::R H AV?N, .~'L~~A. ~ ;'.,arning: Hot val~,d ~s~s~-ra~sed seal of the DIVZSION OF VTTAL STATISTICS, POIK Courity £ ~ ~ Heal`h ~epa~~ment ~is :affixed. ) ~ • ~ S ~ trL~.,.~...... t" I,~,~,~,~ +,,,D E ~ ounL~ ty~ea~th icer and ocaZ :te~istrar ~ ' . ~I A . ~ . r~ L - . . . . 3 R-~~ ~ ~ . ' De I,ocal Re istrar * ~ g 600K17~7 ~l1CFiG~~ ~ 1:3 'w . . _ . . . ' _ " " _ . _ Y ' ~ ' ' :r P~".c ~ _ - . . . _ ~