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HomeMy WebLinkAbout2403 ~ ~ I~ - - _ _ a 235924 . _ i_ - . Te~~ N- 6TATE eowao o~ Hc~?~TM CERTlF1CATE OF DEATH eo~es a BURGU OF VITAL RATIQTIC• STATE FIL6 NO. te~u ~~o- FLORIDA - or0 •~en BIRTH PfO. REGISTRAR'S NO. ~ properl~ ~ ~~C[ OF O~wTN CODE NO. 2. usuw~ w[s~o[Mtt(w~...~.~.de..i pwNtM.wr Rs~wrW~~~iwiMl ~:eented ~~N~ a. Si~TE D. COUNT~ ~nd ~lll t - y~ C T. i De ~l~e~d t. ~5 RES~DEhCE !a y~f-. A. CITr, TONN.OR LOCATIOM t. ~S ?IACE Oi OEATN GTY, TOwN,011 IOCATION ~NSfpE~-C~IrTY 1IM1751 .'A~A` . 1!lSIpE CITY LIMIT51 ' 7' r YES~l .NO? l l 1~. YES ~+0 ~ ~ tU1ME Oi (/J M! ia ~M~itd, /iK ~lltet ~/Irai) ~ LENGTN OF STREET ADDN[SS . QN A FMMI Hp5?~UL OR STAY ~N Ib - - uRT~TUTqM , ~ ~ ti Y~.c ' ~r A YES ? 11~ , ~ 3 NAN[ 0/ ~?st Vw1dlf Laat OATE 1NMf1 D~~ Yt~ oceuuo • °f cnv~«,.ra~ ::i' ; e ::~e :~zc~- oE.TM ;u . 17 1 . S. SFIt i. CO1011 OI~ MCE ~ UANR~ED ~ nEYEN wARP~[D C~. ~TE Oi WRTti 9 ~GE I~aa ~ f rW u~p~• t~ ~YK. - ~ l~t AirtNq) XwW Gw Nww X^ A. • ~ s e• ~e::. ~le. rp w~oowco0 ava+cco Se~t. i OG E2 ( p y 1~ I Ol r IO~. YSUAI OCCU~ATION (Qi/t l/w~ ~/tN1 ~otf 1~. KIN00< <USIHESS OR IMDJSTRY I I. YIRTNPIACE (S7~ff M JHtI/D [~YOfI~) GT12[M ~ rM~T ~1IMA~~ ¦ i t A r- Iari~~ ~wt N rrtis~ b~r, new i/ rdad) . , , •~a~at T' r, @S 1 LCUSc. ,'ork ~i@O. ~.iG' jJ.c.it. Dl~Ck lek ~3. FA7Mfl1'S ~E 1~. MOTNEA~S MAIDEN NAME' er ' e~P..r~s.~ ":i ex :=.i1Zs I er.c,; ,.:~~cn ~ IS. MAS DECEASED CYER IN U. 5. ARMEO iq1CE5~ 16. SOCUL SECI:R~TY AO. 17. IMfORM • tICMATYII[ 7 c~ T I ~ . I Yw. r. ~ otrwl 1// ~n- ~.~e wr ~ Irn ~ww) . rIo lin~c:~oti~:1 A~~~,•714 ::ve. 3:~t.'~erce r a. 1~. CAVf[ O/ OtATN ~E~[t?Nl/ ~~t ttwe ya 1i~t /W (0). ~~f (t).) IIRERVAI OETMEEM . Pun~r~l O~i~ET A1W DEIITN d 1 N! tOr ?ART L DEAM 1/AS GIKEU ~Ye _ . ¦Y~~ IlI• IMMEOIATE UYSE ~ T~v'ZC~~O r:ew.tioni.a ^ lh• C~~- " 3 Lt~..)~`~s i i esr~eae. c..tri..i.~~a¦r. wx ro e6) ^~ia • .1es e?• eaid p.e .u~ 4 ~ 1 o t w 1 tl~se e~wt 1~1. ~ Ydiy /4 rw4?- r~6lstr~t puE TO (t) •1tAfa ~3 = Jliy nrsr lut. . O fMT 11. OTIQ SK?~i1WT CO~WTIOn6 CONTUMJTY~C TO OEI1iM Wf ND7 R[UiFO TO TM[ TEIIYtMILL OlS[ASE CMGT~ON G~Y[M W PMi 1(~) . WAS AUTOPSY I' Aoars •f- ~ ?ERiORMEDT ~~I t~i d~~tb ~ - YES ? n0 ? ~ ! or Deter• ~ ~ ~ ~ 20D DESCR~iE ?bw MUU11Y OCCWlREO (E~(rr wdrr[ ~Jujtir~ i~ P~rt ! N P~r1 !l ~/Ytw !f.) ~ ¦~r~As •R7 ~ ACCIDENT SU~CID[ NOMK3Q . •~p6si- W ~ ~ ~ on et ~ Zfk. TWE OF /!~r 11lwN. p~. Y~o ~ eea~. v uuu~r a~. o y. W ~ 20/. Iw1U11Y OCCUIINED 2(k. ?U1CE Oi ~NIUNY (t. is or d.eW 1ows, 20J. C~TY. TOWM. OR LOU7qM COUNT7 STATE WN~LE AT ~ NpT MfNK[ ~ ~w• ~a~• ~~tt7. oQkt Gll1.. ~ YIOAK AT MOIIR L - 21. J~tbnd~d fh~ d~eti~~d froA~~"-~~"-..-_ ~ 5~ ~~IC~ , to ~ 9b ~nd /~at a~r h,m ~lir~ on ~ t~ 1~U ~ . 7:v . DNth ocevrrd ~t _~m on the d~t~ st~t~d ~bo•e: ~nd to tM 6est o! m~ knorbd/~. f~om th~ uu~es ~l~t~d. A11 lt~is jj~. NCNATYAE ~ (Utpno+tUlt) ~ 2I~ ADDRESS ZZt. OATE516ME0 ar• to 1• ( ~o.p~.~. . ~ ~ ,~ca., ( ~or+ _ ie: ce F~~. ~-~9-63 •CCY~~t~. ~WiqN_ j~ WTE ! • I3t NAMC OF CEMETENY OR CREMAT6RY ` 23/ LOCATION (C~f/.lNt7~. M tN~Af/1 . 11[MOrY l n 1 - ' _ ~ ' l• P~ /t _ t pi.^.e ~T'OV@ ~E~ :eter" : .~~erC@ : i~. ~ t Y. 3. *OlZ j~. FVM[RAl WpE OII S SWMIITURE ADDNESS 25. DATE FECD. ~r IOCAL REG. ~ pEG1STRAN~S 51GMATURE ' n.•.~oae ~ •or.e :'t.?ierce _~a. 5-2~-53 Aru?a ize De:is~n, d.r. ' - FILEO ANO RECOROE~ ~ ST. WCIE ~OUMTY F~ . - R06ER POITRAS ~ 238924 CIERK CIRCUIT COURT c ~ RECORD YERIilEO ~ t~ • ' u ,~i ;t ~-~~~:'.~f-s,~~~'r; - ' ~ : , ~v • I hereby aertify this to b~ s trus arx! aorroct oopy vf fhe Icce~ ~ ~ il ~n'~~ -~,~i~~.,•.1~ t.{;S~w ;~'"r - • ~ Re~Istrers reoord er~ flk in th~ St. luel~ Counry Heihfi Dopaei~ , ••;,'~`„t ' ~ msnt at FoA Plero~. Florlds. ` : f . / ` ' . ~ ~ ~ # (Waming• t~lot valid unless ralsed seal of the St. Luds . ; rt~:• : ;,;~;r° . ' , - Counfy Hea{ih Depattment is affixed.) . ~ s ~ _ ` -a.,.. . ,~=r • ' ` r-~ ` ~ _ N. D. MILLER, M. D. ~ '~~,~+`,~'i~:-`~ t~ ; a q Fiealth Offic~r Loal R~gtstnr ~ ~ d 1'~+t ~ , ~ - . ~ ,t... ` „ ~ • 'n~ } . ~ , ~ ~ ~-j . / ~ - ~ J ~ ~t G-r. uo • ~Y,~wr- c~-a ' :l t 7 1'''~y~t t}. - t Odr D~{A~/ LOCO~ ROOist?s? . ; ~ - ~ _ - . . y ' ` z ~ ~ n - . ~ ~ i