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HomeMy WebLinkAbout2591 241214 , _ ~~.ti.~ - / ti CERTI~Ff~D COPY ~ WE HERE9Y GERT1fY THE CQPY` REPROOtlCEO B~LOW TO BE A TRUE AND CORRECT COPY OF TNE ORtGINAL RECOi~ ~ 7'1 F{t.E ~N THE 9UREAl! OF VITAL STATISTIGS OF TNE ~TATE OF FLORIOA, DEPAR7 .q,H~LTH AND REHABILITATIVE SERVICES. DIVISION OF HEALTN AT ~ACKSON~ FLQftI '~Ii~'' ~NpT VALiU VNl[iS ~NE ~8E , T}fE 4T/[~; ~:Op~DA. UErAQTMENT O~ NEALTN AND MEHA~14lTATI\E {[RVIC[~. OWHION Oi 1itl~l~FfIX[p'1~ ~j~'~-s ~ j' v ~~jt ~'~jl ,C ~ A~„~3!+' ~1~•(J1,~'''~ ~tJ~`10"' ~ 1 - •:~~i`~/~~~R.~~f~~~~ CMl[~. ~Uw[AY Ot VITAI fittf/TlG• ~ ~ U~ A 1 ~ r a •S, `J` . ~~r y ~V~~V'•~ ,.+j . ~ G ~ f ~ ~ • . f • ~ j ~TAT= A[GI~TRAA: O(t![CTpR. DIYIlION b~ 0..:~~ _:~w ~ NfAI~N DI/AAT1~[NT 01 N[ALTN AMD ~'i~:y~ : ; wrN+s~uT~~~Yt ~[I1V~cp ''.~~f, •~f••••'~ ~ _ _ . _ f, ~ E - -.}~E - _ _ - - - ~~Ti sowan or HrurN~~~'.~%el~~;r'~~-~~~~,~~RTIFICATE OF DEATH ~ !ij-O C~ 6~~% ¦UR[AU OI VITI?L fTATIf17Ct . aTATE I~ILC NO. ` FbORIDA + S1RTN NO - REGI6TRAR•8 NO ! ~ Y 1 ILAC~ O/ O[ATN COD~ NO. 2 YWAI R[ND[MC[lR~..~rndt...r !/•..~.a~.~. R..~..~.e~~....~nw,~.! ~ ~N~ ~ _ / / ~ • STATE 0 C~U~lY T ~ , ~1R! ~fi f''~ ~RII'iA .ST. A. CITY. TOWN.OR I.OCATAN [~5 ?~~CE Oi OEATN t. CITY. TOWN.OiI LOC~TqN t: IS NES~O(NCE iN510E CI lIM1T5~ INS~DE CSTV LIY ~IAMI res~ Mn~ • ~IERCE ~ resO i+o f. NAME OF ~//iNf i~ ~NDWI• /bt ~t?tel ~/Itru~ IENGTN Oi 57q~ET AOORESS _ ' ON • i~~r• NpSf17Al OA AY IN 1~ ~ ' ' MIST~TUT~ON C r S):~' ~~'i`f . N S P. ~:J S c; ~N ~ I N S RE~ . res Q no ~ 3. MA1M[ o? Ffra~ Niqft Zwt W?TE Mo~tA '[h~ Yrv ~n"`~«Di~~ ~OLEMArY FRA_'VCIS DI~IS ~TM FEB. ~ 21 S SEX 6 COIOiI OR RACE ~ MARNIED hEYER MANIIIED OATf OF /1NTN 9 AGE (Iw /~YI r~~ ~ ~W UMDU tr 'MS. ,L n M' T MIIDOIMEO ? qVORCEO F~B • Z J ~ L..71 J I~Iljt"ISW~N Xwt~. MA Hwv~ ~ Yr. C7 1C~ I75tl~tL OtCWATqN f CiK R~~1 eJ ~cat dout 1~. KINOOi ~US~NESSOR {MDUSTNY 11. ~U~NM.ACE (S7ett p/o~ty~ clrslt/) 1. qT2D1 Oi slNr ppuurnYr lsris/ e«t~~/ U/e. e~ew !J refvN) SALESM~'J ZSNS~ItZ, A'VC~ S. C. USA li FATNEII~S MAYE 1~. MOTMEIIY MA~pEN NANE Ci.IFF'~R~ DdPIS R'.'TH RIRSCH IS- ~AS OEC[wSEO EvER IN U S ANYED fO~CES~ 16 s0a~u s[wR~Tr »o. q- u~1ORM • NY/MTY~t x ' ~ ,...~ES ~...r.~ ?51-12 -11 OA....W C - 1• CAYf[ O~ O~ATN (B~ta o~ll qs esrx ll~ (~1 10 a1 ltl.) ~ l!(TERYAI {ETrfEEM fAll7 1 DEAT11 ~AS CAUSED ~Y: 01'tSET AlID DEATM IYME0IATE GUSE Andlfau, tJa1. ` V~`~~ ` • r?id ~srr ru~ 4 ~ TO (0) . . _ ~Dae cs~w li). q~~ te~iut~ 1~ OIiE r0 ( ~ O ~MT tl. OT1E1t Sif.liilLYR ~I~ITIONS COKIRIK/iO1G 10 OEATX ~!T N01 R9 ~O hQ iGYt1ML OlSUS[ COND171011 G7YEl1 Lr MRT 1( . MtAS AV j. • /fRFDitME07 ~ YES NO ? I~! ~ID. DESCRI~E 1101M 1N1U11Y OCCURRED. (LGl~to wdt?t eJ~+Ubrl P~t( I M PRt /l of ((t~a /~J € ~ ~ AOCIpEMT SU1Ct0E HpMKIC1E ? ? ? 7Sk TIME Oi Hosr aVe,~l. Dq. Yra P t i ~ IKJURt fA. QF f ~ D. w_ f 2a. IWURY OCCUIIREO 7~. ~LPCE Oi t/UURY (t_ is M~Dort lO~IR. ~1/. CfTr, TOMIN, OR 1OG111pN OOUNTY STATE E ' MNH.E AT ~ ~qT wflllF ~ ~o?/. atrett. o~iK GII~.. dt.l ~ ~ MtORK AT MfONK 21- I~tt~nd~d tM d m / s' . to •nd /~~t san h~ ali?~ on L . pG~ aeeu t en on th~ d~t~ ~t~t~d • o~~: ~nd to th~ b~at oJ m~ tnowfdt~. /roa~ tA~ uuw stat~d. 1 TY ( n ~ 2?D A4DR[SS 2?r. W?TE 51C+iE0 •O/Vi~/I~ ~~{lP.~tR~II ~ 3.~i :,:a pU~O~I. btEy~t~Oh. Z3a. pATE 23c NAYE OF CEMETIR~ ON CREMATONY 23/. WCAiqN (C}f/, (qps, p cw~atY) (atYt? rscrcrti (laccsl~~ F'~Y~YAL ~ METH~t7IST CEXE?ERY TILT~N ~J~iSPER~ SC Z~.~SnERJ1? ~~i O~"t5 ~ ~N• TH ST ~.A~1RECp,~~.q~,(l~,RjG" . RE S T' E F r tn a ~JV T ~ . PI F.RCE, LA . 241.2~4 ~ fy~ f0 pyU ~.ECORDEO ~ ST.LUC{f: ~auNRAS~A. ~ iIOCE~~ 7,~ r•~~~t?T ~ ^ t C; ` , _ No~ ~ ~t io A~'~IC ~ ~ 1~ R ` ~ 'f ~•.1vl.r "~J~I~~ ~i~ ~ . . . i _ `~~t. s-'~ =r,_.+p~ ~„h?~-8.,.r ' z. 3 a ~'.~l tis~." _