HomeMy WebLinkAbout2426 ' CERTI F 1 ED COPY
WE NEREBY GERTiFY THE COPY REPROQUCEO BEIOW TO BE A TRUE ANO Co12RECT
COPY OF TME OFjlf)~*~.~'p~CpRD`.ON FILE IN TNE BUREAU OF VITAL STATISTIGS OF TNE
STATE OF FLO~I~;~~ ,~~~!~~,~.~a ~OF NEAI.TH ANO REHABILITATtVE SERVICES. DIVISION
OR NEALTN A7~+~ .r~~ft~;;j~j~RIDA. ~
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~NOT VALIU UN~ ~t`~~Lt t~+pF FLORIOA. OEPARTMENT Or NEALTN APCO 11EHAR~LIIATIVF
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~~y -R~i,R ~`'-a N[AITM Ot~AwTM[M• Oi HCAl7N AND
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- - - - - - - - .
i~ • '~GERTlFICATE OR DEATH :~ti1~{
~ F L O 8 I D A sTATfi FIL6 NO.
fl~RTH NO. - - - ~L6~STRAR _S . NO. _ 1 ~_Q__ _
1. PLACE OF DEATH ~GOD6 NO. , 2. USUAL R~SIDENCE ut~.• r...-~u~a u~~s It ~o~uw;wn: r..;.ere oec, r~
a. COUNiY ~~,ti _ StATE . t b. COUNiY ..:mi,.~a,_
i.,~. Tr i bb- n~ T
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e. cin ur ~.w. ~~o~.a um~~. R:a sc~.i.: G~srn oF G ciTr c~r a~,a. ~~a~u. .t~u lil:R:~Li -
OR ~ I STAY 1~s ttl~ o1.c+~ ~ OR :~j~ I~~ ~f:
~ ~ ~ TOWN
towN : , F I ~~R' ,
d. FULL NAI+IE OF tlf oot fn EvpiW a uatlictio4 ~n ~tn~t WSnu or Ixattmi d. STIFET 11 nuai ~«utoo~
HOSYITAL OR ADD0.ESS I q~(+j ~ ~~`•J~ J ~
INSTITUTION
' 3 DECEASED ~(First) s Al1ddL> a(I.~t) 4. OFTE lDas) cYc~r>-=
/r~ry~ o? Pr{wt ~~r~~A '~'i' /~T • . DEATH ) r
S._J.~t1.~ . a_. _ ~i;S_
S. SD( COLOR OR R/1CF 7. ?AAlQ1ED, NEYER h1ARR1ED, 0,
A E OF tIRTH L A6E o T~i v o~ou t ~ta~ n cao~~:~ rn
WIDOWED. DIVORCED tewcsrsl I :a: otnc.:a l~ltoetl+ Dais:IIwra .]tm.
F.~t~ . C OL . ; 5~ i , ~ ;
ICa. USUAL OCCUPATION~dtt~ tlM af ~ar~ IOb• KIND OF {USINESS OR IN- M 11. Bjg~ {~~~r. +.ztn~ IL ClTIZFTJ OF WHAT
! s;o~ anrsn: nat at ~~t utti ~nn u nur~d! OUSTRY ~ 1J~a ; i:()'.I~ a~~ i~~ v COUNTQY )
LUEi,dti 1' l~. ~ ~
t3. FATHEt'S NAYE 11. ?tOTHER'S IdA1DEN NAME
r~ ~ n-~
~=ti:r .S r1;I~tON T... .-r....
!S. WAS DECEASfO ~ER IN U. S.ARMED FOACES7 IL SOCIAL SECURtTY 17. INFOIWANT'S SIGNATUR
~ Tu. n~. ar unkno.n) lU sa p a bui ot senfa) ~ NO. .
~ ADDRESS ~~~G . ~ I-'= 1y:t.~•
_L
:e. CAUSE OF DEATFi MEDICAL CERTIFICATIOW ~Nnx~,w amr~e~N '
Eo~ ~b a~ i. OISEASE OR CONDITIOfi ONS[T AN swTH~
t er tiue for (s). lp). DIRECTLY IEADIN6 TO OEA1H~(~~
nn3 (e) r
ANTECEDENT CAUSES
•T)ua doca eot wesa ~ DUE TO (b
rne .iode oJ dri~o. itorbid eonditiowa, (J an~r. ahiso -
r_,ch a~ henrt lailrre. ~ to tAe aboe~ en~w (s) alst.
_~tF.tnio, ett. It ~neaw ~rD tAe rwcerlyiwy e¢tae lsat,
".c diuas~. injsry, or D!!E TO (c)
' c;mpGcation mkieA ~~,OTHER516NIFICANTCONDiT10NS
;r <awed dsath. Cowditiowa eantribrtbty Lo tkt d~otA Aat +tot i
rrfottd to !Ae d'uca~e os eeaditiow em~ain deotA. O ~ Z r
~ i9a. DA?E OF OfElA• Hb. MAJOR FINDIN6S OF OlEIlATION 20. AUTOPSTt
~ iION '
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F ' ra Q_ wo
~ 11~zooaa~~ ie,auJ~ 21D. P CE OF INJUIIY tn or aoart } 2Ic. (CITT OR TOWN (COUNTY) (STATE)
~ ila. wCC~DEHT Wce. hrm, taceaq. ~net. oCw Li~-. { It naai. ~tW IICBALI
su~ctoc j
~ 21d. TIME l~t.l tDVr ~TUr) ISant1 2t~. INJURT OCCURRED 21f. HOW DID INJURY OCCURl - •
s .INJt7RY ~ n~uar ~or~N~u
g •O~t O ITfORR ~ ? -
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~ I hereby eertiJy ~f~at 1 a1(ended fhe deeeeatd from to tha! I Iast aa~o (Ae dcecescd
~ olit•e on 13 and (F.at denfh otcurr d al m., /rom the caares and on tl:c dat~ ..tated aboi~e.
~ 1.e. SIGNATU (D or tiUe) !t3b. ADDRESS 23c. OATEStGNEO
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d U R I A L R M - i4b. DA Iic. NAAIE OF CEMEIERY OA EMATORY ~ 24d. LOCAilCN CiLp, tosrn, or couatp) (State)
~ ':}'lJ , REMOY l~cfts ~ ) t+ ~rT ~t 1.:.[tC ~
r ~ 1~: ~ J: L ~ ~t;
~ wTE REC'D Y IOGAL TRI1R 16 tE F~N S S16NATURE ADORESS
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