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HomeMy WebLinkAbout1371 ? ~^1 . ~ . . \ ~ ~ ~ - w•`._~~.~_ - _ v~.~ _ T~.~ . . ; scgce a~ra o: x~w CERTIFICATE OF DEATH - st.ce ~e xo,_, , sureau ot vital st:tistica ~ F L O R I D R Regtstras'. xa ~ a ' , r s t` L PI.ACE OF DFrIT ' ~ ~ i 1T$VAL R88ID~tCS O! D1CGRa8~: ' ? (a)Guun4~~• [I~~.~1tt DUlrfet 1C / . iD) Pmloet Pne1nM :7 W Stat~ ~~~,r..` (a) l~ntr , (n rft~ not awul~r) (e) Cly. or ?o~ '=T6~S~ l Ti[/h1~ . (c) C/V or~ pq? ot I ! To.o wta~! . ' Tn~n Ida t~ufu Nyr or to~a Umttw wHU AIIRALJ id) \am~ et i~o~y1W or butlt~tbn ~ ' BcnK Na -~'J t~ C~~1~•c. Gt,- - ut noe r eo.ww ~ wuawa ~tn~t• r or ioca ~ (It r~tat. th'~ toeatlo~) ~ ca) Le~ts ec .w: I. ho~tm e~.m.utaua. c.) aus~n ot Fer.+sn aonou~t ~rM Or m At D1al'1 Ot dlatA u 7M. L~~ MW~ . (SO~~ILp RiMtNr ~n. maaLN or l~ys) 3. FVLL NAIiS OF DSCSABED YI,~,~_f ~..CLV'fio-- e/~l C21LtA.ide-s. ~ . ~ - ~ 3(?) I[ ntena. . 1 ~1 8~*IV 3I~ AL Cfi~i7FiCAii02i ~ name w~t ~ ~a• iR I?aM et Dt~W: 1[oa ~ D~y ~'J ~ ~ i. 8a ~LVa.~ti i. Oelor or ne~ T~ ~ ~ ~r HLat~ ~'Y. T'I 6. 81nsb, marrNi. w18o+rM or ~heraN =1• I L~nb~ asrctt~ Wat I~c[MdN tM ~~o M[eom ' li~~ ib ~0~`z: ; d(a) It ma?*1N. ~ do~r~A er Ahorw4 1~uD~a~ K(ot) ~ 1 .tia ee .l' D~_ `;1Jcsn,n.~.a..:-~.-.. ~a.e i ~..v AL,~r allw ~ 1~ lsKZ; . ~ d(b) A~e ot hoaband ite. If alhre .,~r~ ~~t i~atA aoNrttd a1 !1~ J~q v/ lwae ~tatea ~De~. ~ . ^ u ea o th _ . atrtn aau ot a.c~a.ea ' law. '~7) flMr) L Ai~: 7Mtf ]i0~tly D~7~ _ It M~ tL~a ON '~7 ~ DY~ t0 c f. ` 1 ~ ~ 1~. an. m1o. D~N tn - . - - 9. Blrthplat~ ~ Otb~r ooaditloo~ ~ . ( sa ewa4) 18t~ er tor~lsa ooootry) (Iae1M~ q~waay trltAJn i mo~tlu ot dMW) ! 10• llsual odrp~tios ~ I7. industr~ or Muiae~r ]tt/or tindlnp: ' . y~ 1« \am~ r/ V ~ ot op~ntions IInaeet~ tLe ea~us t~ rrtilc~ dealb , ~ ~ 13. DlriAylae~ ([iir~aauo[ap~rs~ttau) ~ ib~ali eY~rsca W- ?sc c' 1L ]W6en sam~ ot anwp~~ . WtfeaY7. ' 1 !%a ~ 13. Binhpite~ - v' , . 2Y. Tt deatA ~u ~ua to a:urnal aaw. litl Ia tA~ tolb~cfa~: ~ ]d. Intormant'~ 81`o~tar ~ (~1 (PrpbaDir) Acdden4 wfeN~. 6o~ukldt (ryedt~) . ]G (R) Addrtss (D) Dat~ o! oawrrtnce ~ (c) R'han dld (aSury aeeurT ' ; 17. Bsrtwl, ccmiaclon or remont' ~ /Cit~r or twrn) (Couat~) lauu) y( 7 (d) Did fn~ury occar tn o~ abaut homt. oa tarm. tn lada~trf~l ptace. {n ~ 1? (a1 Dat~ / 7•• 17 (D) l1uy~_ ~ pnblk pLCet ~r, k11M~a] Dlrector's ~ Sitq,ttt~re ~ w (Sp(~Ct:~ tyy! ol p1iCY) / ~!r 18 lt ~lddreas l/ ~VLile st w~ork' )[e~w o( ]ary ~ 19. Filed f% 7 t9 G~ 23. 3?cnatu» ]i. D. . ' Lotal Rrsiatrar ~(a) Addrest 4 g(~p~ c~ . - , ~ ~Y ~~Y thls to b~ • 1rw a~d oornct oopy af ths bal - . - - _ - - i RepJstr~'~ eroord on flb 1~ t!~ Sf. tud~ Counry Hss1~ p~~ i mrM ~t FoA Pi~r~, Florids, • ~ _ - fIlEO AND RECpRpE~ % ~ , (Waminps tVot valid unl~si ral~d sesl of ths St. Lud~ :j.IUCiE CQUN'f~ il~. , . CouMy H~atth O~psrtn~nt k~ffix~d.) AO ER POItR~= • ~ CLER~CiRCU1T C01i)Ir r ~'K''~,~~=~ ` ' . a, a ' ' r , ~ : t N. D MILLER, AA. D • RECORO YERlf1ED p ~QR ~f t; •~~;r-~ ~Y OffiO~! d~ 2 i~ .t ~ " . ~L7I ~~tfK ~ j ' .~~s ~~yr~~ ~ - ~ ~ ~ _ - q _ b~ pc..~' ~ ~~1 . _ Ai ' ~ 7 wF ~S • ~ ~ -s,ti~r ' •..r,? i ~ ~ ~•~a~•a? i ~ 1. ~ ~ ° ~ ~ , . . . . ~S~ Y f ,y - j ; t fii . - ~ . ~h~~ t a ~~a' . t • SVL~1~ - • ~ ~ . ~d , ~ - - - - - _ J i=r- ` : . ~Y' 4 ~ jr- ~~F~P` 'i t t ~