HomeMy WebLinkAbout2060 " ~ \
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253439 ~
FItE~:~ Ch.tt7 IFIED COPY NO. i;~~ ~
(FEE WAIVED)
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i Pl.oe oi Birth State Board of HealtA of Florida ~
W _ HUREAU OF VITAL $TATI$TICS
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pNwq Resl~traNoa Dl~t. lp~:.~...._...«......» 1tet~Ke~ 1r' -
iat~ 'lyw~
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p~ ..'4~"'~~t 1lxBl~rt4 occn~reil 1n hoipital
or otLee
loititutlon SI~
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ai?ID~ l~ o*i~
8 FUI.I. NAItE OF CBILD....DRT1d.Ya...~A tr cn~~a u noc ~.t .am m~c.
.u lementat re u ed.
~ 0. . nm r n or~ ~r ~ . -
t'Atl I oe otherT ~ ot Dtrth msteL ~ 7
~le ~ Z@d blttu--ss~=..=z----•1~~
(To be an~wered ta avent ot Plural t:,r) ~ (~toet~? •(Da1) (Teae
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t RTsBID~iC~ pi~. ~ 14 AEBIDENC~
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Noi~t~8es~~~Ph'opitaaa~atA~ F~ ItNon-reil~t ~I..~P4a~ce ted State•s
! OO~.OB OR !0 M~ AT LI19T S9 li COLOlt OR I li AO~ AT LABT i~
' AACE ~i ~ BIRT~iDAY -lean) ItACE ~ t~ BIATHDAT T
1T BIRTHPI.ACS
~ 11 SIRTHM+ACS ~ - + -
~ (Clt1 or Place)~....~._. ~~~r._....___. ((`It1 ot Plac~)r.....r.r.~_._...._....__._._........
letatr or Cuuatc7) Fee. Pa lecate os Couatq) ltep ROSs
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~ Nrture ot Indu~t (Natun• uf Indwt ~
nm r o eea o er en u me a rn vs en ~e
ot Birth ot Child heeetn certlAeQ and fncludla thL chfld) ond now Ilrl _~_bnt oow dead c Stlllbora....~.
~0 CEItTIFICATE OF ATTENDING PHYSICIAN•
thsL it ooourred on 16 1~i3 .
i nerebr cerucr cnac t accaaaea c~ birch or tLf. c t~
or the date ~bo~e rtaNO. <Born allre or ~tlllborn)
•N7u~ 1ker~ w~u N attqWL y1~7/~'
~1aw ~s riawitq fra! 1M tat~e.
faw
iwlaeq ete.. NNW awlte lils srtu+~. b !1 lSl~n~ture) ........._r.Stl._SCl...R~~.~_..~L...~..
~tltri~n etil1~ L~ae t!M s~tlY~e (PLldclaa. l[ldwite or Pareob)
..r .ti.... .a~.. ~.w.~. port~'r_ierce ~U
ur..re.. w~. waare.e -
ti (31se~ aame ad8~d feom a aupplemqtal r~ ,
port_.,-.. , lf__ E! Flled._ ]f._....., iwoal ~sar
I.ocal 1teLl~trie M l~r~ O. D. lr~. L •
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- - _ • Sfate Regatrar of
. ..+i 11'".,'~r~! s ~ l, H. C. _?uralc
~t~h':~ Vital Statistics, hereby cenifr the above to be a tcue aad cocced oopy
~~~~'••.~r of the original cer+ificate on file w this o~ice.
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; Given at Jacl~sonville, Florida. over my signa~ure aad the o6tcial ~
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,.t : 'G~ _ - ~ • i seal of my of6ce. this the. _........'~'.!!e._._~...- ..................~y
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.til' ,~te~~` , ..r _
_;.~a~~- D'uector. Bure.u of V 1 Stati~tia.
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