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HomeMy WebLinkAbout1777 ' 2319'73 : CHAI~LOTTE C(lUN1Y 111~/11_711 1)fl`AIiTMFNT ,~1", ~ j v; ~ • ?1 ~ . ~ . ~r~~ ~ ~.e rl~~ f (~~~A~.!_ ~~~~a~ ~ . ~ I. ~ ~ ' ' ~,~te? r;~~~~~~~. ~ ~ ~~~~~~n . „Q~? - ~ ~ . ~ • ''~r . PIIONE NE. il -1181 ~ ~ ,ti. S~ rti '~on• ~ CFRTIf"ICATF (ll"C1FAeTH ' Ikp~dwr~d oI Ilralll~ ~mI RrI~al.llil~lhr ~rr~b~~ F L O A i D A 1GTE ?ILE NO.- - IN\hNl~ tM Itl \I111 , ~ rtior n~•w..~ Qf ?tlNi iN flil:l~ttRAN ! NO ?[IMANtNt INK OECE~SfO-NAME ••~a. +,M~~ u.. ~t1~ ~r I•~~IH •rOw~r, O~r, ki n«p1001 t01 ' i~ST~uQ~OMS ~ i ( ~,1: ~ t ?t . I~ "l ~ t1C1^ 1! ~ 17! 2 RACE rwrtl. MIGW. ~~I~K~r wo•~~ AI:F ~•a ~ rr~• !~.~»m~e r o.. ~ b~ti M~1~IN . e•• j~Mn~tr pf ~(ATM ~.ru~~ ....a i e..~ f rM ~~NI fiC 1 tlfCNt 1 ~'~IMr~• ~ t . 1 ~ r• ~ '~~};i~ "i'l - -1 ; ~ ~,~lotte CtTY. TOMM, Of IOCATION (7i (~fAtN ~~•er <m ~r:~n- w~~ir~iii M nt?~fi r SmUt~n?t ii•::r ~ v~e...o rv.r~~ ~ / ~/li ~ ~ l~~i~~~ M(~ / n~'un~ a;znrcia ~c:~ 'ti~tli~::sl tt°i•. l;,~:;~,iL~l STAiE Oi ~1tTN ~u NO~ ~w v~•.~•r~ C1fIlEN (X WNAI C(~M1~1 M11f~IF0 NE~'f~ MARMED, ~U~Y~~~RN': 4p)l~ G~Q~WO~M ~a,W ~ ~c+t.w.~. ~ wK~Wf[1. ONO~CE~ r w~r.. . : s.., ~ro.w..a 1 `Z ~ ~ i" ~ ~ ~1 ~ r ~ . , _...~o+<..uo _~t~io__ . Ji~ - :_lI•riecl. _ :_.ti .J • ~i ;.mi~ ..~c. p~~~ S~CIAI SECUR1Tr WMeEf USU~I ~XCINAIKIN ~~.•H ~~O ~n~~ .vw~ na~.rt ryr d r~~ nr iprsr~ts ~ INy1S1~~ ~_~1fD ~r +~w~'+'t h~•, N ~fn~~D ~ . ~r'„'~o... c~n ~t 7 i~ 1 ~ 1 , v ~ t ~ i„ . t . ~ n .~..~~»c~u.oa l~_~1,~.~ r~ 1~,It CPI11_.. . ht. .lC. : U'( 1 ~C~ _ "3 ~.~0. .c~.tisw.. RESME?~~E-SI~tE C(Nl?~/r Cltr_ t0~. M I(X~tit»~ waM~ ~~n ~~.~t~ ;te~Et wHO r+uMSE~ ~ . 4~~! ~ ~f l OI y0 • iN i'ZOT'i~.~~l ~a~~l~li'1(?t t~` }:QCt ~,};'12'~C~l..~ u~ ~~~1 ~~.i ri:~brose I,d:1C r~tMEt-r~w,w[ .~n. ~.o ~..•,nK~ ~+~mr.~ w~~?e •~n• .~ea~ us+ ~S t ~q ~r•1 ~.1 INfORMANT-IJAM( MA~1?X~i ApG~[SS 1{fM/~ M~~• MO. Cn~ M M~w, t~~h. 711 V~ ~r~ ' i. c-G~ P T: 7~C~~, 1 ?AfT ,1 DE~.M W~S C~USlh ~t !(qf(f t`•~~• i>NE UUSE ~tf IM~f f01 (e1. fAl. ~NO l~ • r ur. ~.u ~ M Nh~~Iw Owy~t ~NO p~rw , I~ i.ri6~•p }...ai . . - - _ _ _ _ . . _ . _ _ _ _ _ _ _ - Iel ~l~~~~. ' ~ K~ - lSi~? p~" ~1 i.: t>.ai!'a7~• r ~OMDIf1ONS, ?~n. .o I ,b, ~ ' t~~fDi~l~ C~VSI 10~ I ~r.. n~ ~a • ~..~~N~K~ h~ { s~~r~rG twe uwOe~ 1 lt~w0 C~YSf l~f~ ; f ~A~i / DiN MI(~Nt CpJpi1N1N5 rnM~NV~~w. M Dr.n. ~ ~r.r N~~•1e r~ i.~va ~n.P. ~ti r~n . mr ~Urp?Sr-~--~ u rE5 ~f~f ~~wO.w01 CO»- / M wn~ t~Oft10 ~N M~t~r~wu10 C/Wf! ~+~~_~~d~lc~~-~~ /~-t l~ _t.-~'~~'T+__~-- ___'1~~'11L IihOl~tw f?•obeM 1 ~CCIDfHI, SUK'f~( M hA~~ ~ MIU~r ~.M+~r eN• ~1~N1~ ~NOW IN/U~? Qf CURt(D '~•nf~ w.rvN nr ...w~. ~r r•p ~ O~ ~~~t rt!r ~ ~ N(3r~K+df. O! IM~OEIf~Mn+fO ~ ~ti1 ; ~ L~- { IN/URf AT WO~I( ?l~Cf O~ 1NNMv ».>rl •~W. \~Mt~. r~nn~~. ~ In(~IICM~ r~~ql~ ~ r p r.n . r~.. t+~ ror+a a~ry ~ ~ ~s1eUn +ei O~ ~O~ n.rv~ ~p.~. H. ,anr~n, f ~ ~ }M ~ ~ CE~iqtC~T~ON- ..•r.... e.. .r.an. e~. .i.~ nn us• w.~.n n.. ~ oM n~~ri• Ot~rw OCCUt~fO .r n.~ ?utl. O+ M IM~SKI~N~ IO ~ Ww+~r P~• ~~.w. N~'r O~R. ~w0. W NM MS~ H ~~n1«oto rr1 )~7 ~ / ~ / W.~ W r~ ~.~O~~~GGf. WR ~ F 7~• o~c~.s~o /i- ~V ~ ~ 7 7 ~L_ ~t~~__ ~ [ ~ n.' : SCir~w~ ~o n.e cw+os~ ?~.ao t CE~T1iKAi~ON- ME6~C :1 [t~iwMlif (,y l~Wll1N11 Y ~•vt n. .~w »n..~ ~y.n. ~i ~irir~.~• .-rnv-w~..-.n r..D ~~•rw•nb+ d ~M vx~. .r~ ..~.~s.~~..~n~. ~ tvw,n.~ ..n~..r e.. rOU• oe..~ oeewao o.~ +~r o..~ ...n n~~ M tr/ .~~.Spt• ~.~qp ~ Jt~ M ( M ~ tERt~f~F~-?~IAMf ~..n i tN.i~~i - ~ - - - ~ - ~ . ^ 't~~f~,r - o.•. •~u~ r .r / ~ ~1~L,r ' • ; R11~ ~ ~ ~p / / I% ~ 'i~wNwG A~OftSS- ~f~rqnf 1 , i~'r~~ T: • ~L~F.~ . :o:~:. ~L t,• t~. , ;'~r ? I ~~r~i.' ~ , ~iNW. CRfstAT~ON. Hwr.w~ «V{I/~~ O~(RFMAIf)H ruul K~t an~x~ ~•....r tr..e ~ s+ec~n, ta~ -C.^.i0`.'31 ~7~~ ! ~~I'~~':1 ~ rt~ ~t~n1 ~•I'~,~ ~~}1~2'l n~ 1 n ~ . f)I'~ }l ~arolir.a ~ DAtE .,rry..r n.. .r.~. ~~~nue~l u7lr~f u~•~1 r.;!i ~f~M/CS ~~•~~~r o~ ~ro ~ n.. o~.n.... n•• ~ ` INLi.,:'.. 1'i"i'~ Il~s, 1 U~ • i:(~ ' I i:,trj•. .i }i 1. i•}:.)..~n. i'I,~ ~iSL ~ S. ~617 ~ t iiECtO~ ~~.r~~•i ~F•.~t! y:t. ~p _ o~r~ ~~.ta ioc~i ~w~siu¦ ~~+.19TC ~K ~ }N ~ ~ • ~ i ~ ~ i hereby certify thP at?~ve to be a truP en~l correct copy of the Local RPQistrar's record on file in the Charlotte County Nealth Department At Punta Go?•4,~ Florida. ~ ~ (Warning: Not valid unless reised seal cf the (:hArlottP County Il~alth ~~,~rtment is afPixed.~ : - ~ Fi~Ee nM~~ ~~CORDED - - . ~ ST.IUC+f i~l'HTY FLA. - -t ~ ji ~.•i' - . RO;,^- • ~ ~AAS + /~i~~ ~ ~ f.. ~ t~ r. , ; ~ ; C RT , . , ~ t~~ -1. Il ~w ~ r~-G~. ~ qEr~F~ ,cv. , --1 .v.~.l'A. : i_. . ~w+ ~ - • ~ 4 ~ - ~ . ~ ~=I ' ~ ; ` r r. Cou~t Health Offic~r ~d Loc~l f~egist~ar ~ 1t 3 s6 PM 7~. . . : - ~ . ~ - . _ , , , ~ ~ ~ . , - ~ D~te ; s..' Deputy Locel Regi st~er ~ ~ ~ ~ :a- " _L" ~ ~ 2~19'73 l ~ ~'o~c~~ ~c~~~'~ ~ ~ _ - ~ , ~ ~.._..,_.::k t_ _ - ~ 4.~.,