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HomeMy WebLinkAbout0179 . •.T ~ERTt~Fi Et~ COPY ~ ~ . ..~.~..w W~ HtRESr CERT1~'1f TMS COi'V RErIlODUCt~ •ELOW TO et A TRU6 AND CORREGT GOPY Of TNi ORtGfMA6 R[~ORD ON FILR lN T11t dUR~AU OP VITAL STATISTIC4 OF THE fTAT~ Of fL~~. D[~ARYiA6NT OF HtALTK AND REHABILITAT~VE SERYICES. CIVISION O~ NEALTN AT JACKSONNI~.L.ft. ~ QR~DA. _ 1~~.5 , •~y~ ~ ~KOi VALIO ~lNL[i~ TM~ ii~.~~I T T~~~~S~+Ow~DA, O[IARTMtNT GF NEALTN ANO R[HAOILITATIYE tt11Y1C[f. DIVIiION OR M~~M q ~:y~~ ~ ^ O t` , 1 : Nt.. ~ ~ : ~`~+~+G7~+1 ~ r . ~ ~'~7~~ ~ ` ' J`~ a . ~ ` l ' r ~ ~ ~Clt1~I. WR[AY I ViTAI l7ATli1Cs 24ii!$$,Z . s~t ~ $ . -r ~ - . ~~~?r. .~~t~~. • ~y~ • ~TAR KGIfTwA11: 01R<CTWI. OirI110N ~I ,j ~ ~ =3~ C ~~Yt - ~ ~uw~TN - os?wwYrar 0I NtAITN AMO . • r'~~` - ~ ~ : . R[NA~lLITAT~Y[ fiRVlti~ ~ :~~;7 Y~ ls-' ~ ~.i - ` ~ ) ~t ~s ~'TAT[ ao~o o~ Nu?~TM " ~ , FICATE OF DEATI~ ~ ~ ~ - - - ellRtJ1U OF VITAL fTATIfT1q. i` ~ I:: Z- - . STAT[ FILE 7~ ` F;~rO$IbA BIRTH NO rf'~ ~ S'~'' ' REGISTRAR•S NO. ~ ~ 1 ~LACt OI OEATN ~ 2. YsYAI RCSIOiNC~ !~?,?w~ ts+~M Md 1/:..e.haw- R~wN M~ M~r~:r.) ~ ODiJMTY . -a•~* ~ pV~1V ST~TE n r A. COuNTr 1- . ~al~n ~..ac.. F'1~ i a S.~ L~~-ie A_ C~TY_ TOYYN, 011 LOCAt~ON t. K ACE Oi OEATN p7Y, TOMIN, OQ LOG?TION t. K RESlOENCE UK10E CITY LIMITSI INS~OE t1TY UYiTS~ Lantana, Florida ~~s C~ ~o O ~ t. ° i c H c~: --'t u~ ~ 1 .~5 D No O MAME OF (!J ~N ia Lrpitd, ~Yt ebrt! dbd~l IENGTN Of I. STIIEET ADDRESS - X, 7~ ~ MOS/ITAI OA ON ~ fA~Y/ uaTiluT'o~.E.j'.j8. `~lb@PCi1~.OS1S ~DS fi~y~~b j nR ~ V:'nl1~ res? Mo(~ 3 ~d1r~ Oi~ fl?al ViK.t Lu! - OATE Mawt~ !b/ Ytu rIP~~ WI e: O S(=~J ~ ~ I~ ~ 1^. ~ 3. 1~ t T'' DEATN 1 ~ 1? j.y. l S. SE% 6 COIOA OA RACE 7 M~RNIEO Q MEYER YARRIEO ?~~T~ Oi 07RTN 9 AGE IIw ?r~r1 ~ Y~ UMRJt N NK. r.,e eotyr? x«w n... x.... x:,. .~91 ~ .:ti^_? t ~ rnouwco0 avaecco A~^11 ~ 1 ~P:. ; ~ IOa usuu_ oCCW~Ttow fCiu t~u~ yrat Iwt 1~ K~MOOi WS~MESSOR tt~OUSTRY 11. ~IItTMrIACE (S7de ~r /Nty~ toYOfr/) 12 UTREN ~ t~NT CqWiRrr ~rri,y .w y w.tia~ t~~e, aea iJ rdvell Su erintenR~r.t A~a^}T~F-~t °~~~r ~'t ~okl~ I~ic~: v~^;t LSA 13- FATNEA-S NA4E 1~ YOTNER~S YAiOEN NJ1YE " ~e~„a-nir. ijili~r S~^a'~( last n~ r.P~: ~il e) IS NI~S OECEASEO EvER W U- S. AI1rE0 i'07tCES~ 16 SOCtAL SECURITI/ NO. 17. INiORIrA a sICMATYRE I Y.~ ~ r~.~w) 1ll ~n. ww~ w~/W~ ~nwee~ ~O '~r7-`~~-r`~( A[b~u w D{;_n~.~_ .~y.ir.~ ! 1~. CAYf[ O~ O[ATN (Sata ql/ ~at cawc pn Gwr Jr (SI. t~~ (d.) ~ INTENY4L ~E7WEEN ?MT t. OEATN MllS CAbSEQ ~Y~ ~ ~rMCOU?re cwsc c.. PNI~lMOFIAi-- B(n'H UPPE~_ L03ES ~N1p~nt sTN F - - - - c~-r~..~~..r. o„c *u ~r. ?UI~+:ONARY NBE.TtCiTLU6ISL_i,HRONICz O:..D-- 20 Years :aid p.e rx r. - - - - - ~Dae caru (il. - r"'~"'~i ~x i: a,E Tc c~~~C-A2£I.E " -A.'4D FI~~SIS -1`~ _Years O tMT 11. OT}'.Q S~'+~N~lfi COwClTI~Q C(/t;w1~{/fMy TQ pEATM 6Nf NpT REUi[O TO TMF ~ERYIVI DISFASE CAlO:iUO!1 G~YEN W fYT . MAS AUTOKY KRFORUEDt ~ G$N~iALIZID AR`~Sc~I~.,"LEt20~7.5 CORONARY ATfiER06CLEt~OSIS resQ Mo0 " 20~ ~ 20A DESCR~~E NON WURY OCCURRED (E~tn a~?~rr yiwjt•~ in Pv: / r P 1/ irew :tJ ~ . ACCIOENT SiIKIDE NOYKlOE . - ~ ~ O L ~ 20c 7~rE OF !/wr ~ - - - t u~~. a1. ! iv . ~ oUUR~ a. w. ~ ~ p D• - ( ~ ZII/. IAI4N1 OCCURREf) ~A[ ~UCE CK lNlURY (f. M M Y~Otf aOAt. ~IJ C1TY. fOwN. 011 IOCAT1pN CC1ihTY STAii ~ WMKE AT ~ MOT MfMtLE ~ lacler~. strttf. a~Stt Ald/.. ttt.l ~ NpRK AT 1MppK ~p 21. !~ttendwi th~ deewNd hom . s OV_ ~ a. to _ OV • f nd lut sar him di.e on l ~V _ ~ 1 i D~~th «curi~d ~t ~ A rn on tA~ d~f~ st~fd ~bore; ~nd to th~ b~af o! m~ kno~lsdte. /rom th~ c~uNS ~tat~d. s ~ u. uoa?TV+ecpj,g~RT O.~ c r« o• riu?ROSS~rM.D. ~ ADDNESS~taT.IA~ FloT3d8 wTC s~e~o ~ ~ . ' ' . S.E.F~tII~4 `!~3 H06PITA£~ Nov. 26 1 bi 27~ BWtlll. UfWipN. Z'7D p?TE 23t N~~iE OF Cf METERY OR CREMIITORII 23d LOtAT~CiN ((Y~, [erw. or couwtil (JTof[) Il ( lpftt~// ^ al 1=/~~ :'t. PiercE Ce~et~^ Ft. Pierc+_~. ori^2 j fU RA~ T NAT4RE AppflESS ~ 2S. UATE NECO. BY lOC1lL NEG. M R AR~S SIGMATUIIE r,'t.Pierce F1A. ~ x ~ ~ ~ - FfLf0 AMO KECURDED ~ ~ • i :T.IUCi[ C4UMTY FLA. ; ROCER POtTP.I?S ~ ~ CLERR CIicG31T COURT ~'n ~ PFCCRi~ tiF=~~:£D~.~ ~ - FE8 I~J ~ 34 PN'73 4 ~ ~ 24'7~82 ~ = ~ ~ ~ A - - ~ ~ S~,JVl1 {RVl f ~ ~ ~ ~5~ yi~ _ ' - _ ~w r-~"~~ _ . . . . _ .n - : . s._ _ - _