HomeMy WebLinkAbout1677 ~ _ ~
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s~te ~~a or x~~n CERTIFICATE OF DEATH State File No ;
Bureau of Vital Statistics F L O R I D A Registras's Ne D r
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1. PLA~CE OF DpEA.~TH~•p Z iiSUAL R~IDSNCS O?' DF~A~BD
~ (a) County --cTA . n~-!
J .rw J~ Dlstrirt N ` (a) State. ~ r~~~L-~-~~~ (b) CouAC~r• ~
~--y
' ~
(bI Preclnet Precinct N ~ ~ '~1'n ~ ;
~ t~ ( W rite name. not nu~aberl . (c) Cib or To,~+• %f ~ ~
_ f
j ~ c) city or clty or / ~ (It outside CitY or wwn, fs. te ;
~f df.t,L[.(,2i ~ Town A2o ~b -
X~
~ Tovm (d) Street No~~ ~-u-t~•c.~~.rw1 ~L~~[.4<'iV , ^S'~_
~ p (d) Name of hospital or Lutltutio ~ ~
ij ili not In hospttal ar instltutlon, wNte atreet number or location) (e) (a~p p! pbrefan tountt~t y~~ '
~
~ (e) I.ength ot atay; Ia daspital or instit t
~ At place ot dea ~ • ~ 7~• IIiII~
(SpcCl~yr w ~ears. moaths or d~ys) _ _ ;
~ -
~ 3. FULL NA11iE OF' DEC ' r -'i•~ ~•~J ` p~• f`~~
• 3(a) If veteran. 3(b) Social Securl+7 lIhDICAI. CfiBTIE3CATION /.3
~ ^ ~ 1 -O,~ : ~ fh .,L(_i~.ci
' r~ AiI[1Q ~~par ~~`L[_~~ j~jp Dd~Q OZ Dl~~: ~OTI_--.~~_~iy
; C ~ ~•r Yeas. ~ `I ~ -ti' HouL - ~
>l_1 ~ _ :.v_~ u.
~ c y Se= S. Color or r 21. I hezeby certlty thaL Zattended the deoeased fro~"
y~; ~6. Sin81e. marrled. wldowed or div O 1~
A(a) It marr~ed. wido ed ar div h~ o! (or~ ~o D
^ f. that I last saw h-. altve od. : a~
~ 4 ~ ~a ~ ~
that death o c
c u r
r
e d on t
he d a
W a
a
d bour d
a
t
e d a
b o
v
e. D n r
a
t l
o
n
a~ ~ 6(b) A8e o! husband or wlfe, alivp-- ~ .Years Imr~edfate Cause ot dea
u
r ,o Blrth d~te ot d ~ ~ ~ ~
~ ~ (month) (d~Y) (Yeaz)
"r. ~ 0 8. Are: Years Montlu D~s IL Ies~ thsn oao daY Due to
~ Y ~
o L 3 7 ~ 7 ~e
~ ~ / Ji
~ ~ ~ 9. BlrthP ^ ~ ! Other CondiHo
G:~ (Ctty. Wwn or oountY , (State br lnrel8~? oouniry) lInclude Dre6nan4 wlthia S months of deaW)
j
~ ^ ~ 10. Vsual ocavpatio ~
7
~ 11. Industtp or busfn ^ ~ ~ ~1~ ~d~+:
n .r ot oyerati UndeHins
~ (et/,,y~v. i ~!.~.:s-!c tLe causeto
s ls. N x6tehdeath
~ k. l3. Bfrth la ~ . ~ (Give date o! operatloa) should b e
. charred sta~
s° lt Maiden nama-G~i~-c~wst/ ^~!IJr_4-L t;-_s~-~cGJ ~ o! auto ttstlcally.
~ 15. Blrthpla ' ~
I[ death was due to ezternal causq, fill in the foIIow,ing:
u
~ 16. InformanYs SiCnatur~_~ - ; /'•-~C•'~'~-v ~ (a) (1'robably) Accident, s?licide.~hom! ~e~lEpeeifyl ~=-~-c.c~Ct-L~..~~
I6 (a) Add!~ . _ rJ* / -2iGtJ ~ - , (b) Date ot ~ ' ,
(C) Where did WtaY o0Ct1t - - : .u~ ' ~ -
17. Buriat. cremauon or remov~t n L~c.-+c~~.t_.~-:,._./ ~ (Ctty or town) (CountY) (state)
17 (a) Date SF 8 l7 (b) P I.+ ~ Y i d) Did 1n7urY occur !a or about twme. oa farm. !a lndustrlal pIs?cR
~ . . - !n pub13C PIaCe~ ` - .~-!l~'r:.~} .
id. bl~neral nsreccor'. siena -t~a~ r~:r sf ~ (svecifY tyDo os aL~e)~ 9 ,
V. S. No.4 ~ Addr ~ ~ . ~ ~~-Q.J Whlle at wort?_._I
-~~e) , o! iA~~•!~~ H
.r ~ 23. S~attu'e 'r~ ' K ^ v -yLl~r _ ~'tA"^c.Vu ~t.'D.
~ _ :I . ?~t_ /
1D. Fil ~ ; I Local RegLctru (a) Addces~-;-=.. r?4 ' te S
' -
~ ~ 238 4'71 ~o ~,w R~~~~ _ ~
`tIC1E COIIN Y ~
~rROCER~pP~0~~I~YTIIAS . . {
Vlz~~ ~f+~~~f- ~~1 ~-""~-~-~-•'r""' ~
• aECMIO vERti1E0 ~ , t
I hersby aertify thw to bs • frw and cort+scf f• w' :~J`' ' . ;
Regiatr~rs rooord on ftb in th~ St Luc1~ 00Py af ths 1' 2 OS ~H ~~Z •;i,•e.'' y:, ~
msnt ~t ioA Piera~, Plorid~. He~hh D~ • F . . , ~ ~ -i . ,
m , < , • ,
(VNuning: Not val;d unless nised seal of the St. t.uds ~ - ~ : ~ : l~' ~ ' ~
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COUf11y HQa11~1 ~R~ftflfeflt if ~ffiXOd.) - ' ~
~.~'.ti~'.. ,
l ~
N. O. MILLER, M. D. _~~t-~'l~' j( a 1~~ ~ ~
ty Fisalth OfficK ~.l+ocd R~glstru n~?~' . • ' ~ ~ ~
. ~ ~
~q . . 31 ~ ~~,i~~+y' r" ' i
7 - ~ - ~7 ~ [~.v~ t~_ , ~ r
- - ~1 - G.,-~v~. E,,--~ ~ . 1
Od~ D~eputy Loal Rec~l~re? ' .
~ ~ BooK~t~ i~74 .
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