HomeMy WebLinkAbout1811 ~ 1"1 h 3~
~ a~~un r~1
Fi~EO •No wECeRe`~c ~
~ st. WCtE COUNTY Fl~. l~
r ROGEH POITRAS i
CLERK Ct~CiS~T COI:RT ~ ~
RECORD ~f RIFIEO ~
~ 1~ I I 18 AM ~TZ CERTIF[CATE OF DEATH
. F L O B I D A "Twts riu Ho
BI N. R OI RAR•t NO. ~
1, pLACE OF DEATH CODi No, t USUAL R6SIDSNC6 tw~.•re.w+n..a u~ruaw.:
couNn r~ sr~TC w couxn
_
s. oR c~ ..w. ..4.~.M u.w~ sus.w a lEN6SH OF o cm w..w+. ....w. n.u,, .~u. sus.w ,
~ _ • STAY Iv ub N•rl Ot .
~ TOWN . TOWII „
a. wu ?uwE oF w•.~ r wur ~ rwWU.ti a« a,.K R wu~r wooeE~fs ~y '••L a« rn~w
~ ~ HOS/tTAlO~ ,
INSTiTYTION ^ -
~ l. NAME OF Ilfed) b. (]IWdL) (Lre ~ DATfi (Ya~t~) (Dq) (Yrar)
~ DECEASED . D~1TM 2,~ 2~ 1 r
f M n ~ c+ -
`g i. SEX i. GOLOI Ol RACE 1. NARRlEO. NEYER WtR{ED~ f. DATfi OF litTFl AGi ~L u~~?a~ ~ tu~ v~~~n rn
WIDOWEO DIVORCEO ~~4) L~ I~
trale Col. ''~rried i~ar. 1~ 18q2 ~i0 1
~ 10~. USUAL OCCUMTiON~O~w tfa/ d wrt ~~b- K~NO OF {USINESS OR IN- 11. ~IRTHtLACE ptw ~r t~y~ ww~n! l2. CIi1ZEt~l OF WHAT
yw, ~y w,.rW yr~.~ 1t a~tuM) ^ DUSTRT COUNTRY)
~ La~~or ~Trove :Jork ai...brid~e ;~a.
~ Il FATHEI'S IL1Mi i~. won~~es wuo~ wwE
Q Robert S::effield ~ " .
ic, wws eccewsEO Et IN Y. S.AR?IEO FORCESt i~, soc~w~ ucu~tn iKCO~uw~rs s~cw?TU~~;.i t:. Lee Shef ±'i eld~
~ G~ ti«. r~ s~wI lu s~. dw nr ~r aur H w~la) NO. ,
~ ~ AOORESS r- P i.~ r
a i~. c~?us~ o~ ofwrn MEDICAL CERTIFIGATION ~N*uv~u. .m.~u.
! Bnter oab ou e~w f. OISfASE Ot CONDiTfON oMSn wNO oiwTM .
i ya La~ !or (1). DIRECTLr LF/WIN6 TO DEATH'~~ ' p i ,
F ~ ~1
j ANiECEDEIIT GuSES f+ t_' g'~ O D~ T' S
' ~S7w den wt ~nw Y~riti qwiiNew~ U ~+w. a~~i+WDUE TO n-
W tw/~ ~l 1riwl.
( we~ u Iwsrt l~its?~. siN N t11~ ~bM eaw f~) sf~h
E ~ a~t~ewi~. ~ It ~ww~ ~*I ~w OUE TO c
~ e~swyL'~
e~sK ~v~ A OTHER f16NlFICANT CONDITIONS
~s~ 'tw~ rewtriMti~y to tkr dsath Drt w~t =
~ ~ b f1Y~ d+s~aN es eowditiow ait~ia lest~.
1la. OATE OF Q? ~ Hb. MAiO\ FINDtN6S OF OfEL?TtOli 10. AUTOKTt '
3 rn ? No ?
d ' ~ (pne~Db) (bwit~) 210. /IACE Oi INJURY ~aR. L or ~boat 2~c- (CITY Ot TOMM (COYNiY~ {SZAtE)
~e 31~. ACCIOiMY M~b I~eM7. ~trwl. ~Ae~ ?1d4. Ma l If Rd. MM~ 1ITLL1
z ~ •UICID[ ~
3
a 21d. TIME P~wiW Wv) Rv) 21~. INJUIY OCCURtED tt H D UR t
j ~ Oi *f11lt~T 110it%tlt
a INJURT ~ ~o~c ? ~tro~R ? ~
~ ~
~ l hereby esrci/y ~lwe I ousnded eh. deccaud Jro,n , 19;a,~, to ~-~3. . 19.~,3thnt 1 Ia~~ aa~o tl+a dcceased ±
~ ~ - :
~ elive on~ l9 and tAat dealh oceurred at ~ 1'~~ a m om the tawu and on tl~e da~e tlated abov~.
~ ~ ~ 17a. SiGNATURE (Doar« or t+t7~) ~7b. AD~RESS 7k. DATE SI6NE0 !
~ . r~ s
~i . Ci • F-, enton }r D ~i r '
~ Q Na. ~ U R 1 A l, GtE1~I~M 2~. OATfi 21c. HAME OF GEMETEtr OR CtEl1A10tT 14d. I.OC~ATION (ptl, fo~a, ac eoaaV) (6bte) ~
j~ TION, lEIAOVAI 1~1p1
; ~ }~~ar~ al -1- Pir.e ~rov ~ ^ .
„ ~ DATE REC'D fY LOCJ1l RE6ISTRAI'S 516MAiU~F 2S. FYNERAL DItFCTOR'f SICNATUtE AGDtESf ~
~7~ ~rs~ r p~' :r_.~i c r~ c » A rl Q~ ?l
3 . - '
1 her~by oNfify fha b b~ • trw ~nd aorrect oopy o~f fhs Lo~al -
itepistnra rooord on fils in 1h~ Sf. Lucl~ Gocrnty
HeaFth D~parf ; . ,
`Y m~nt at foA P1~toe, fbrids. ,,~t*`•~ ' ,
~ (Vyami~/p.~:~ ~Not vua_li_d unf~u rstsed s~ta_f of tyh_sJSt. tuci~
~{7~I~ fl~o~~ R +~M~.~ ?=aT ` ' ~ ~
.
# N. MIIIER, M. D. ,
= County OffioK d. Rpittru :
.
~ ,
- ~ ~
; D~pt~1y Laal t~a(strar ~ , :
,~y
-
~
~Vt~ PJI~f
6001t `
~
;
~
- - -
_ -
,
~ - o
,
i~` ~
_
~ , . . _ - . - . . _