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HomeMy WebLinkAbout1712 ~ r ~ ~ v ~ } ; • - s - ..~_.y _ _ ~~~0 - - -I ~ ~ ~ CERTIFICATE OF DEATH a '~s STATE F/LE NO FLOHIDA ~ ~ ~ CiRTN PiO. REGISTRAR•S NO. • i. PLACE OF DE/?TH CooE Wo. 2. USUAL RE IDENCE txa.e. aeew.a ur.a :t ~..stwtue: R.a.xx. a.ror. couNn ,i 1 ~ ~ V ~ i~ n~~ ~r ' _ s. couHn ..m,..~:,e~. r . !:%t : t~.C~ - __i:•-Y ---:t~--~'U-`_C_= ~ b. c~Tlf ~ ur «m+. ee~a~w n.u~ ..u. aunai.~ c. tEtrerH oF ~ c. c~n cu w~.sa. oora«u. u.it.. .ru. ncn.,., . O~ ~ I jJ STAY (~a ~nts ~laoe) µ OR `v ~ T01NN ~ i__ L~_'i. C-~_ i ~}~-"-:L'~ ~ TOWN , i. ~1_-f_!~' d W LL NA)~1e OF (tt rt l~ ~e~N~ ~c Wuuasr. g~C suwt ~itrw u 3au~W '1 d. STREET lIt rrnL stti~looW~1 ~ ~ Hosm~~ ot f . S . C _~f.r ~ jr _ ADDIESi f n ~ ~ l - I ~ . INSifM10N a. NAME OF a(P't~st) ~h (Yiddle) a,(Last). OPTE ptonth) (Das) (Year) DECEASED . ~ y~ ) " fi'rD+~.Riat) ~ ~ - ! ! , + ~~i,l DEwTH ,~'..l ~eJ - ~ ~Y~'~ . SE7C i. COI~ORORRAUe 7. W1t:lED. NEVER MARRIED, DAiE OF tIRTH 1. A6E~~~ ~ u o~~u ~~~u ~~~tu~ .~s ' . WIDOWED,DIVOtC~ da.~u7r) lrt s~nA+a) '~~rlr' La~ Iiwr~ st~s. , ~ :J ;~y~: :L y_ :r_~t ut. ~ ~ '1 -l r I - ~ 7:x USUALOCCU?ATlOlltat» tud ~t +rl I~b~ND OF ~USINESS OR ~N- ~ ll. tIRTM/LAGE (SUU or t.n~t~ ~wrtn) I2. CITIZEN OF WHAY . ,,;:,.e„ne~.o.c.~..ny,~ya~w~ltnu,w) DUSTRY , • ~ ~ '`COUNiNYt ~ .._r c,_.~ :~1 •_a--~. • J- ' _ - ' . F~nir~t~s t~E - 3 ~a. Koni~Y wuu~ wwe ,n r ' - ' • 7 ~ / . L:~~~" • ~ , ~ i ~ t ' S f.( - C ~ - - - = - - - . ~:i. Y/AS DFCEJ?SED IN U. S.ARMED FOtCES~ 1~. SOCIAL SECURIiY 17. INFOAYAN7'S SIGNATURE _ i Y.~, ay ~r otew) (II 7~ ~w sar ~r i~w d rnw) NO. ADDRESS 1. UiC ~..f ~::4 1 9 / ~ = i Ig, CAtISE pF pEJ11H MDDICAL CERTlFICATION _ i _ ,~~nwvwi ernviceN 3 ; Eater aab one ea~e 1. OISEASE OR CONDITION ' r~ ' oNacj wNO ourp . ~ :er tine tor (a). l1). DI~6CTLY LFADIN6 TO OEATH'~~ i_ ~ • . r~ - . • • ~ _ ~ ' ~ ~ ~ ~ ' ~.i ! sad (e) ~ . ~o' . i , ~ ' lr ~._i : v: :~_C.: _ ..C.~r • t~ ; ,_..L-:.-~-C..L-<~ 'r:- AN7ECEDEM CAUSES ~ ~ ~h" d°`~ "K'a" Yori:d e+sad;r;.w~, :J ssr. r~~aDUE TO (b _ • :F_c +wis el ~ri~D. ri~t te tlu sbore c~~w fsl ~trE- ~ rirk v kos~[ laits~i. _ , c::hcai4 eZa It t~sta+!"! ~~~O a~ DUE TO c) :'r.t du[a+R ial~rl. MI -orsri:cat+os ~~~~a~11.OTHER.SI6HIFICANTGONDITIOHS - ~ ~~s Coad+.+owa c+w~tribrti~y b t4e dcatJl brt aoL ~ srlat~d !o ti.e df~raM ~s evwditiew earsirD d~at6 ~ 19a. DATE OF OtEiA- Ifb. ?U1JOR FINDtNGS Of OtFiAiION ! 20. AUTOtSTT i n~+ r~ res l_1 ~o ~ (IY:Dtai~) (~YS) 21b. fLACE OF INJURY (e.e.. in a: at~uat ; 2~~- (CITY Ol TOWN (GOUNTYJ (STATE) iia. ACCtDEIiT ~4 ~7, k+~•'~~ 0~. f It [~e~1. ~tau Rti WLI su~t~oc ~ ~ I:d. i(~!E lYr+t?) (A,s) /Tari lNew) 21~. IHJURY OCCUARFD 21t. HOW DID INJURY OCCUtt Ne ~F iM1UAT OOTtN3li INJUiT ~ ~o~a ? ~r ao~c ? I nereb~ tertify ~hat I attended lhe deccased jrom ~ 19=~ ~o ~"l 19 11+a1 I lasl saw thc ciccca~cd a~it;e on ~"~i 19~ ond !).at drath occurrrd a! l~~ r-m., /rom ti~r. aiusca and on lhc dn~c statcd nbnv~. . .3a. SIGNA7URE ,(De¢ree or titJc) 23b. ADDRESS 23c. DATE SIGKED ~ . i ~ ; , _.r / / - . ' ~ ! ~ ~r ' ~ ! • ^,.i/ • . C ~ . .-L i ~c:~~ - f_ j % =~a. 8 U R I A L, CRE?IA-'2W. DAiE a'~2k. tiAME OF CEMETEiY OR CtEMAiORY'' ; Xd. LOCATION (C~~ town. or count~) (State) ::^vU, RE~lOYALTSisu~ ~ ~ 1 ~ ! - • ~ ' ~ `l . r~J ! . + - i ~J . ~ ~~-i J^-at~ ~ ~ ~ . ~ : / I " •~I=Zi i • 7ATE RcCD tY LOCAI'RF615TRAt'S S16NATURE 2i FUNERAL DItECiOR°S Si6NATURE.~, ADDRESS. ~ - ~ ~•i, i~l ~-``6~i ~r: ~f- s ~ - ~ ~ - , ; - ~ ~ _ ~ s.~~.~.~ f~~- - = ! - - - - , f1LfD AMfl ltEC0ii0E0 ~ ST. LYCIf Wi~ITY fU: . ROCEF PO~TRAS ~ar~71Gr1O . ~ ~ ~ t~a~eey oentfy ~n~s ro be s~rw end correa oopy of ~s c~~~c c~~tCUiT COURT ~ ~ ftegi~rds reoord on fik In th~ St. Lutl~ County Htdth D~ftOCO rEfi+F1ED.~.....~, - _ ~ ~ ~ ~ ~ A~t ~ 2 09 PH'T3 ~ `trt j ~ . j M/af~11t1~: NOf V~Id {RI~eSi fi~fOd 1A0) Of 1f1A ~ ~i~ ' . _ Coust~l tbehh Dopirn'nant b sffi~c~da ~ ' ~ ~ ~ ; ~ . ~ - ti-: ' _ . : i:, . f. N. Q MILLBZ IIIL 0. ~ ~ : . . T l~Nf V~/i~ ~ - ~)4~~}~~]• 1~~ .~i ~t6i . y - l ~1- ) 3 U.v~ Ceo c~ . ~ ~ -r `t ; _ `L.~ p~p~A~? t~oad ~yh~ . i, f-~-~ I ~ ` ~ ~ 3' ~ :,~;`'1 ~ [;~y_•.,~~ini ~~~!~i;; l ~?~,t~.A .«r < ''~'~~sl i..'~Tl 8o~z~3 P~i~ z ; ~