HomeMy WebLinkAbout1479 . . - 255202:
i~~s te- 1TATE eowno o~ NswLTM CERTIFICATE OF DEATH a
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~ ~p~qTy STATE A. COUNTY ;
e~ oi:«a Volusia 4-02 Florida Yolusis
1 o p!~- D. CITY, TOWN.OR LOCATqM t. K/LACE Oi OEATM t. C~TY. TONN.OR LOCATqN . t. IS RESIOENCE 3
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fllt. L$~t0^.A ~@f1C~': YES~,] NO? ~ t.OT1A B6R~^.~ TES~ MO? ,
I. NAYE OF ~lJ iNf i~ ~NpifQ. /iK ~htN ~flrtNl ~ ~ENGTN OF I. STREET AODRESS ON A FAIIMI ~
MOSPITAL OR N T IN IA ~
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3 MAY~ Oi ~+f ' \liMtr LW 1 DATE . Mo~tl Dq Yta
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v ~.n JON.~: GAAY J~~INS ~TH June 10, ~9b3
S SE7[ 6 COIOR ON NACE ~ yANR1ED ~ NEVfR MAIIRIED? ~~TC Oi MRTM 9 X~4 ~ D~w N~ Y'r~.
y r i c• 1`'~81e ~aE'I'~ MID0IMED? avaeceo ROV. 2'J~ 1892 'j0
~ p 1~ 1111 ~ ~a ~SUAL OCCU?~TIOM I Gir~ tisl e/rat M~r I~D. KINDOF ~USINESS Wi INDUSTNY I1 ltRTNPIACE (S7dt M/stn/~ tor~l?~) 12 CR17F11 aF ~1NT OOIMIRYi ~t
.ftA per- I..i~o.wuNrati~~hk.rn~~/rd'ud1 t
..n.p~ Hinister Barnecvilie, S. C, USA - t
Dlack lek ~j_ FAINERS NAME ~ ' I~ MOTHER'S MAIOEN NANE 3
or
t~p~~rlt~r Allen Jenk~as Un~cnown
IS w~5 OECfA5E0 EYER IN U. S. ARMED iOACEY 16 SOCUL SECURITY NO. 17 1Nt0 S SICNATYR[ ~li~abet~t L Je~cifine ~
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• 1[!f 1 D 71 ~ PANT 11 OTIEII SIGI~KANT COND1710NS CONTpMITINC TO DEA1N OUT !qT RRAlEO ip TIIE T[RYUYL DISEASE COMOiIOM GIYEN III fART 1(~) . wA5 AUTOKY
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MORK ~ - AT WORK ~
Z~ l~tNnd~d th~ d~ce~s~d lrom{~ to _ •nd bat a~~ h,~ ~/i~~ on
D~~th otcurr~d ~t 1V ~ 17 M_ m on th~ dit~ st~t~d ~6or~; ~nd to th~ b~at of m~ kno~rbdN. /rom tA~ cauMa ~t~bd.
~i i i c•¦s tz• s~o~u?TUwc ctar~.~. w rut~~ 2I6 ADDRESS ZI[. WTE 516NE0
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~o.p~.c. a - Cr.arles J. I.uke, II Coroner Daytona ~'e~.ch, Florida - 6/14/63
?tturate. - ~~~u. ~~~Tqll. ZjD OATE 23t N~ME OF CEYETENY OR CREMIITORY Z7/ LOCATION (CS(/, fNCA. N tNtRf/) (Shf[)
REMOr1t 1ptt~//1
Bu.~laf b 1.5 6~ Ft. Pierce, Fla,
Y. S. ~612 j~ fUNt N~L MNE OR 5 5~6NATURE ADORESS - 25 DATE RECO. BY IOCAL REG Z6 REGKTMR~S SIGNATURE
Re~. ~pS6 Heroert :ho~rpso n D~rt»a Beach 5-1~-b3 Arline Q'` ~M ner - Dep.
- - - - - ~
CERT i F I ED COPY y~ r
~
ME HEREBY CERT I FY TH 1 S TO BE A TRUE AND CORRECT COP~' Q~~cT~••.,~ ~ .
LOCAL REG 1 STRAR' S RECORD ON F i LE I N THE BUREAU OF:';Cl~./!L"'••-., ~i '
~ STAT i ST i CS OF THE VOLUS I A COUNTY HEAITH DEPARTMENT..;•;,;, s`~'•: :
(Not va I i d un I ess the Sea I of the Vol us ( a Count~i: _ ; ~y~
. ~ w..
Health Department is affixed.) - =
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fIIED : MI~ R~CJRDEO '.,t
ST. IUC~~ i;i)UNTY FLA.
RG~~~=.=•~~TRAS OCe 69 s rar
CLE?~: ;,~tT COURT •
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Mar 23 I si PM'73 ~ Q a `
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