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CERT i'F I ED COPY ~
WE HER "~'~bRT~ ' COPY REPRODUCE~ BELOW TO BE A TRUE AND CORRECT
GOFY O~ f~ `~~D ON FiLE IN THE BUREAU OF VITAL STATISTICS OF THE
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STAT~ ~F'.''~~ ~AENT OF HEALTH AND REHABIUTATIVE SERVICES. DIVISION
OR :tli~;~ ~ FLORIOA.
.
~N~~4 • '~ifE STATE OF FLORIOA. DEPARTMENt OF MEALTN AND RE1tABILITATIVE
•<AYl~Ba ~O ~~CIf IXED.1
. ~ ~~"Y°
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.-l.~'.,}~ " ~ CNIEF, ~UR[AY OF YITAL lTA71lTICi
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r : ff . ' ~ ~ • ` ~ . ~ 1 ~ \ • `b~r w r~ f ~ ~
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~TE',,,k-' s~w~c wts~srwu~_ o~R[c~ae. o~vinoN
~.f . wE~L7N - OC/ARTYWT O~ MCALTM AND
~ RCMA~~LITATIY[ K~VI~~~
~ cEfrriFicarE oF o~a~ 230af
F L O R I D A ~TATE F~~.c No.
SI NO_ REYitBfRAR'9 NO. ~ ,
I. RL.ACE OF DEATH CoD NO. Z USUAL RESIDENCE ~wf~. a.oww u.«i ~t ~mue~x~oe: r.~taeae. wtw.
COUNTY a STATE b. COUNiY ~ wa~aWa~.
Dade -~Q ~ Florida ~adc
b. CITY 1u auu~ m--x;r.:. t:3!:.. .z~a sCaaL~ c. tEN6TH OF c CITY (It m+aE~ earoasu ua~u. .rw a~xu.~-
~ to°wr+ 1.4iami ~'J~T~lrs.~~ ~.lia~ri
d. fUll NAME OF ur me m?o~cr.,i or ~i:~cuuoa s1.r .ue.c .a~.u x keuim? d. STREET ~u ema~. c~.• ~um~
HOSPITAIOR ~ ppp~ ~
INSi1TUTION ack ::t 'os~ 2124 5 '7tn. Street
i.DNE/CEASED i(~int) b. Uliddle) a lla~t) t~tE (]~mtL) tDa~) (T..r)
r~. o. p.;xti L Z" E KECX'~H ~~?n+ Oc t. 6 1952
i SD( COLO! OR RAGE :7. MARRIED, NEYER IdARRlED, DATE OF ~IKTH A6E ~L T v~¦~u
WtDOWED, u1roRCED ~~u,~ wi s~nea.,i? ~mw vv.,$o~, ~
~ *nzle Whi~e Sin~le IJov. 15 16b6 85
! • IW. USUAL OCCUMTION(QM tta! d~ri' ~Qb. KIND OF dUSINESS OR IN- 11. i1pTHPLACE ~eWy Q toee~p ~~y ~2, CITIZEN OF M/NAT
j aw ~.da~ soK a sv~ues w•. •..u u nRLcf; OUSiRY COUNiRY 7
amstress ,.zdles Wear :^.icaeo ' 1 i ir?ois USA -
~ 1~. FA?HER'S NAMif 14. MOTHER'S MAIDEl~1 HAIdE
f
~ : ~u O : s
.IS. WAS DECEASEO ER IN U. S.ARMED FORCE57 I~. SOCIAL SECURI7Y I7. INFORMANTS S16NATURE
¢ (ia ~s. or ~s) (II m. [iT-~ar ar da~es ot ~arstnl _ NO.
~ E ~wo~s 193~ ;d. ~ . re~
i~ c~?use oF o~?n+ MEOICAL CERTIFICATION ,n,n,v,w ,crMSO,
~ ' Enter ontr ~e caase DtSEASE OR CONOtTtON oMSCr w~+o orwrn
yer liae for (a), (6). DIRECTIY IEADfN6 TO DEATH'~~~ ~
and (e)
a
~ `"°S~ 0 5`~G L~-~Za S I S ~ 11A 4S
~ ~TAII jOII AOC AKQA OUE TO (b
tks wods o7 d~ri~p. Siwbid condi:sow~. if an1. YPriAD
, asek a~ A~art fa~ir?c. to the abose cassc la/ ~;aF
~ artAenia. ~te_ /t meawa'irD tAe t*der[7r=i9 taws ~+t. DUE TO e
~ tke di~tate, iwirry. or~ ~ 7 ~ •
; cornylication v k i e h OTHER 516NiFfCANT CONDIilONS
ca~ued deatA. Condilioru oo-:n6Ytiwy to tke da~atk brt nM ~YPo STA-T~ ~ PN EuM a N 1~- ,
~ selnt.d ro t)i diwaasr or mnditiow eawiR deat4.
~ fj Ha. DATE OF O~ O -'19b. MAJOR fiYD?N65 Of OPERATIOH ~ ~ 20. AUiO?£Y7 • i
rp ? . po C7' ~
~ ~ - ~ ~ f
i ~i`rca~b~ (saeeusl ,iic. PUCEOF INJURY l~.t.m~rabovt 21a (CITYORiOMM (COUNi7) (nA~) .
~ 21a. weetuenT ,._9-. rarm. hewn. r.net. die~ bWt. et~? It r~t, ~eau E!,'Yala
su~c~ne
~ MOMICIOE - ~
2td. TIME (~tcow) ~DV~ ~s~, iII.nat 21~, INJURT OCCURRED 2~1. HOW 1 INJU Y t
INJURY ` rN~~[~T sor~rNit[ .
ro~c ~ RTYOi[ ?
_ :
~ ! t2. 1 hrreby ce~lijy lhal I atientc~ t'ne detec.•ed Jrorrt ~4 , 13~_, lo ' :
18 52 . lAat 1 laat iam the deceased
j! alivc on ie/6 19 ,:~~i thrti dF h occurred af ' Jrom IAe cawca ond on ihe date atated abnte.
~ f' I1a. SIGNAT tltte) Ilb. ADDRESS I3e. DATE S16NED ~
~ ~ Jacksor •-emorial :~icspita 1~/7/1952:
_ ` 21~. B U R I A L, CRE A- 21b. DAiE l2ic. NAME OF CEMETERY OR CREMATORY 2W. LOCATION (Cib. tawn. or eo¢pb) (8tate)
~'TION, REMOYAL ~soectt~t
~ ~ a ~
~ ~DA ~ 'D Y LOCAL REG RA F1~ti€~J~L C.""'v 'Tiii~ B Fllil~~ Z H4me
J~ V !/E6.
~ ~ ~T'/Y! ~~~1 &Siami Fla.
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