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Home My WebLink About0682 t~ -x - , . ` ' ~CERTIFIED COPY 252452 . . W[ HERteY RTIF'Y1 ~M< COPY REPRODUCEO BELOW TO 6E A TRUE AND CORRECT _ COPY OF THl~RIGINAL RlCOR~ ON FILE IN THL 6UREAU OF VlTAL STATISTICS OR TNE STATE OR f'LORIDA, DiPARTM~NT OR HEALTH AND REHABILITATIVE SERVICES. DIVISION OR HEALTH A7 JACKSON\j{LG~;,-, pI.ORIDA. - - /NOT VALlO UNl.Et9 TN[ t ~;~FNt~~~y,0~ FLORIOA. OEPARtMENT OF HEALTH AN6 REHABILITATIVE •[RVIC[~. OIVI~ION OF N[~~1l.~/~T~ ~ . - ~~f.'~ , i ~ Y:a . ~ • -~f • G?11CF. lYIILAU O? VITAI ~TATIf71G~ - ,..;r~ Ll'F/ ' 4 ~ 11~ • :s : 'r -'~•",t'i •'C'~• ~ i~ /'_,~~~V'~~ ~ ` ~ ~ t J~~ I~1 r iTATt 11[GI~TRAII: DIR[CtOR. DIYI~ION VI ` t : ~ ~ MEALTM ~ OCIARTMlN7 OF M[AL7M AMO --..:.r" • ~c~ ~ . 1 R[N~~ILITAi1K 1LRVICl~ - :1.i~ ~ a~ - . .rwry.-~ . . . • --•...'__.ft'~.~c~.r:r:~ ~ rM~~rr _ ~ ---L~.. ~ ~T +zs,-~ ~ ~ ~ . ~ ~ :.i~:'t r#..~# ~ t~l'.f'~r- ~ _ . srac~ a~ra or Hww ~~t?TFICATE OF DEATH ~ Q3 scace ~~e xo._ ~i~!'_i~.-~~~ _ _ ~ Bureau oi V~tal 3tat~stice . F L O 8 I D A S~ '9 RegistraYs No. _ b _ • ~~P 7 2. 48UAL R ~ C6 OF DECP:ASEi~: 1 frl V'.~tt[f ~~~~~'~jlw /L~L~~~ ,~.tr+el \ ~ ! fa/ %tate Ib) County i ii., f~..d.a r.~ iM tWr1 . oot nam ce1 Clt or To~s u~ CM7 ~r ry~y w ~ / ~l > Tor~ T~.rn ~:o. 7 ll[ ouUtde eitr or w~n limrt~. ~rritc RURwL) 1~1 :~ame el ~o~plbt af MKItYtlos 1 6lte~t !\o. ~ llt pst Ip Dprpttal Wtltrl?~, .rl~tt~•[r u or Iae ~ d It raral. pw loutlonl (el 1.loFtl~ ot stay: le Uo~pIW (~p ~~U~ tuptb~p ~ ~ \~7 1~) Citlrep o[ Fbrel/~n enunlry' ~ At vlarx ut 4eath " ~V '7'~~~ 7r oe no ~ a[ ~es. nam~ eoYntryr ~ ( l r~eeaser y.a... mue~e. or aar~ r ~ 1 I'CI,i, YAI[E ~?Y i?PJCEAHBD , ( ~ ' 1 ta1 It •e~ran. 3 ~bl ~ ~ Il~lh_~C~l~It7CATION ~ i ~~'1~`R'' w xo. wee ot ce: c nar ' i f i Be~ S_ ~tor r . Year hoar ~Ihw ]t. i 2l. hereD7 cen eat I attendeA ths deceaa~d haa ` 4. S:n6k, martkd, wb~.red or divqced ~ ' 1 6 fa) It ~arrl.d. ~ or ro ..f (•,r~ • 18~ ~ 1~„~,~: ~ite M ~Aat I saw h~ n-r u IY and that deatD ocrurred on t date and buur tatM a~me. Dar~Wp {/p~ A~t M Ua~banA ar wl[!, if tlMs ~ ~ rs 7 7 ~~`tte o( death ` ~ 7. Birts Aa4 ot ~~ceu~~ ~ lsoaWi (A~~3 (ritN ~ • ? ~ - _ • : i~ Is+e: 1'~es lio~tat Dal~ 1! !n~ tAan ooe daY Ihr to - ~ ~ An. [nin. 1Mx t 9. B~Mptaat ~ - - ~ . toan ot eaYnbl t8tate o~ tolfign~eo ry) Other ~'ot~dRbn~ yi~ (Inci e presnancy ~citAin 3 months .~f deathl l~~ l'.a:a? awpatwo 7 ~ii4 - ~4~ lt. L•.r,.r.ryr nr 6us" M.:.,r fmdin6a: - - . - . i i. 1~. - ope~atton ~ 1 2j'~ ' = t?t tauk lo - 'j+. ~ ls. [s:nAptu. ~ borld~n~ . _ . (Gicrda operati ? tVrRrA ~1w- c~ 14 1~a24 . r.arr at uto~vcy _ • lLctkalls. ti ~ i t: . snn~.:a,~. _ - - - - - - ~ Y2. It death w~aa due to eat.•rnal cau~ra, tlll In the tolioamx~ t ~ 16 lttu--aat~s &~aator (ai ~Prohaf.tyi Accidmt. saiciAe. Aomicide (t[+'cif~) - ~ , 16 ~a1 Asite~~ IG) Ihlt ot occurrence ~ , ~ le) ~YA«rc did injuty .+ivr' P.a' sl. crcma or nmoral+ ~Crt~ or townl /~`.wn~y~ It;~at~~ ` i~id tnJury- orcYr in w sbout homr. on (arm, in lneu~trial plare. ~n 1: (a' :.v~r 1: IAf {wMir plicrT . IS. F~fitai f3~r(+~Iw'~ oiql f IRMclfy yyr o( piaee) Nhi4 Rt wo • R ,e ~a? ~as.~.. Q' r ~o i t: N. l:+e~ ~ ' ID ~ 1 23- ~~pua'n . n. ~ u ~ lwtai /tKblrar (a) wA~ttM w4 ! • ~ f ~ - t ~fa n«~ eF~DRDED ~ve+~ couurr Fu?. RO;EF i'~t; R~tS ~c f!1 tLr P1on~~~T Ij1't1Q1 . ~ , . a~~ io os aH ~7~ ~ - 252452 - ~ aooK 213 v~ ~$1 ~ ~ ~ ~ ~ ; , ;