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HomeMy WebLinkAbout0879 ST`IU~iE .OUliTll Fl~. 256 I Q4 fl ~~•Jf w ~l'1' Ci?URT ~~K COUNTY HEALTH DEPARTMENT ,~N t 3 12 s6 PH'73 W~~~~~~ MIL4 JR.. M.D. ,_,r ~ CERTIFICATE OF DEATH ~q~..~.r.~ oi H~.l~ ,.1 R~6.b+l~air.~. S...ic~, STATE Fac No. avn~on os ~w~n+ F L O R I D A 6~ ~"'~'~'~^~'~R"~^° REGI6TRAR'~ Nn. Z • ~ pECEASEO-M~wE susr ..ww~ wr SEx OAiE Of OEAM uo..rw, o•r, ~e.~ ~ ~ 1 RACE •~wn, weow. u.eMC~w ~wwM. AGE-taH w.e~~ ~~t.~ u.~wr ~ w~ OA1E Of i1~iM ~ra+w. w,, counrr of oewn~ ~x. ~ a?tta+r w~nw.+ ~~un~ ..oi wn warn a.r~ *W ~ B A A k. • ta Ct:Y, TOwN. at ?oGrw?a or oewrn wwe cm ~wrs 1iOSMtAt OR OMH M ~u ..o~ n. amea, c~e srRn ~.se «u+n~ ~ s.eun ~es o~ Mo u L . SiATE Of ~1tM ~ v uor w Y.3.~_, w..~ Ui1Z8! Of WMAT COl1NTRY MARR~EO. NEVER MARdED. SURVIVMG iu wre, c~ w.~ ww~ ~ Cow~+l WIDOM~[O. OMORClD t YKY~ 1 ' a A. Johnso~ soa~u scansn HuwEe uw•t acwwnoa ~o~w ~.w o..~o~ ow. www .~o~. o. Ku+o oF wswESS oe ~HOUSrnr rO~twO Wf~ !rM M ~lTM ~ ' ~s. u. tE5lDENCE~3UiE COUNiY ' UiII. TOWN. OR lOGT10N Msw cm arm STtEEi AHO NUir R . ~ srew~ ns a w W IM. Ik t~~. Ib. Lf faTMH-IUM! n~si r~oe~t ufi MOTMER.~MA10fN NAA1f ~uR wo0?! tws~ IS. 1~. A tWORMANT-?~~E w?~lwG AOQRESS ISTNR Ot tIA. ?W.~ cmr oe ~o.~.+. v.w, ar~ 334.50 ih U~ ' ~ t1.N1 u~Ilt11N Iw~t~ L DEAM WAS GWSEO ~Y: (ENTFt O/~l~ Ol~ff CwUSE rE! lwf fOR fe). (bb k1) t~7V1lM ONSR ~MO M~~1f . 1j. wnle..A twf! C ,~D/YlL ~G~~Gt~F/YG~l ~~"Gli~t-=.~/~ rJ . . - - COMMt1OM{~ 1/ AM~~ . rwK~ o~r! ~~3~ TO ' ~....ta.n c~u~~ ~m, ow ~o, o~ ns w to«seaw..ce o+: ~ sr~~~NO r~a u»o~~. ~n.ro uwse us~ E ; AUTOKY IF YES w~n s~MS~MCS con. ~A~i N. OiMER SIGNWCANT CONDIilONS: cwano..s co.~rwn..o ro on.n. wn.wr aureo ro uuaa c~rer n+.~.n ~ ce~ . ~ ~ns o~ ~.o~ youia ~M wreua.«.w cw O~ O!?1M i Ib. ' Ib_ 1~ ~CCtOt+~ , 91~d A !J i..oMr~, wr, ~e~~ ~ MOUR HOMI INIURr OCNRREO wN~! O~ ~rNio n~ i~~~ ~ Ot ~w~1 u, rt~w r ~ r Fq ~c~es OR WOfTFU~1WED ~ ~ !0? lOt M. I01. ~ tNlUR11 AT WCR! Il.?CE Oi INIUR'? u Mcw. snee?, r.crw+, tOCAl10N ~ snef? o~ u.e. ..o_, cm o~ ro+n., s*•re ~ ~ ~s~tannso~~+ot orrKtreo..tK. ~ven..~ ~ Ib. 70f_ p! ~ CE~IRCA?ION~ ..0.4w O?t rGt rO.~n~ O~~ T!u uO 4St t~r wr/w!~ ~1+r! O~+ ~~+0/WO MOt n!~ nM Ol4M QCCURtfO ~T iw! tiKi, On aM ?NtS1O~N: rO~7M Mt 7tY ~00~ ~fTtt Ol~YL Iw011~1 WTt~ ~?O, q 1M! ~tSf , /yry To , rz ~Z a a tta wcuseo sp~ UV i { 7p ~ lli. ~3 tt~. t1~. p4_ ro we c.use~s~ u.~n CE~i1fICATipN-MED1CAl EIIAMwER OR CORONER: o» me ~.s~s w woo~ w w.m rwt oec~wrr ...s no..ou..po oe.o ~ e¦...w.nw a me wes .~w~w n.e u«esnwrw~. w,w or.aw. ..a«rw w. .r.u ~ ouw ouvrm o» w ww ..io ow w rwe u~s+ sr.ae. ~ Al ~ ~ CEItT~HER r ` ~ ac~ nne CATE S~/Grt' t , w~,rua~ ~ tla I i /"v ~ ~J I 7A. / r _ / ~ ~ 1Jc ! ~S Z MARNKs ADO~ESS~CEf ~I{~E~/~ CG ~C [i Oe ~.~.0.'NO. C~R O~~/ ~y (3~, Ls ' /L % v / G ~i~ ~~Z ~ ~ WbA~ CRfANiION, REMOVAI CEME~E1lY OR CRfMATO~Y-N4Mf IOCATION un o~ to.+.. sr.re ~ snan ~ u ~ 7N. n Q N~. ~ ~ Nt. • . DwTE ~~.o.aN, w?, rt.~~ FUWERwI M E- A?~M wOORESS ~ sr~eer o~ ~.r_e. ..o., cm o~ ~o...., sr~re, :~r ~ ~ zw - 's -uner Home P. . . x `Oyb Lakeland ~'la 3380' F ER IU~lE RE(SI ~SIGN OwR •'~Ev~r[D l •G~iiawq - _ tSt ~1 ' ~ ~ I hereby certify the aoove to be a true and correct copg oP the ~ocal Registr•art~ ~ : ecor3 on fils in the OfPice of ~:zo DiVISICAT OF VITaL S'i~TISTICS, at the POLY: ^0`.~~:rY HEALTH DEPART.iGtvT at 'rTIidTF.P. HAV~.'P~, FLORIDP.. . , , ~ - ` - . .i~- jj,: , . i /1~~1 l~ ~ oun~y ~ea . ~ A~~ ` ~ ca Re~ s rar ~ ~ ~ . „ . I c.if::Y~ ~ r~. .c: ~ ° ~ . ~.i:~`~i~ ` _ ' ~ ~ ~ Qc ~ . ~ ila~t3 TS9UA~.~. rr'~~' ~ l~r ~•-Y` Deputy Re~is~•^ar ~l,~.. . . ~ ~ i 3 ~n~irs ,ii1Ti S`,'T_C J ~ :~T~R:7I:~1G: Not Qulid un'.ass rai~$~~;~¢'s2 of fihe DIVCSIO?i 0~ VI ~ , POLK Cou:~t5~ Tiealth Depar~~:ent i.s affix~c~~ - 3~~r z~..~ . ~ ~ R 215 ~77 ~ _ _ , ~ : ~ ~ ; ~ ~ ~ ~ . _ v _ _ _ * ~