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HomeMy WebLinkAbout1305 - - - - _ _ • . • • CERIIFICATE OF D~A7H t~ ~ . prp~rlmenl ol ~ le~ilti and 1teF~~L1~ilalire Ce~rltey F L O 8 I D A 'TAT6 FILT? NO. ~~,l~Y ~1F S~/0~~ 111E, OR ~llNi 1N ~"°~n`~~"~pO ~ REGI6TRAR•5 NO. ![tMAN}N~ INK UECEASEO-NnME • SE7[ DAIE OI OiAiM ~ ~oNi., o.*, ~t~t ~ S:E r,xM~tCOt 10t ~ncuaa¦s ~ HSRNETTA . ~ ` ~ ~.br»~ry--~~-. ~ Q7 RACE ~+wu, wtGtO, wW~K+M ~wo~.», AGE=a~st v.+oe~ ~•eu ~w~~ ~ e.+ DAIE OF 6tkiH ~..o.+rr, wr, ~~pV?nY Of OEA1N • - !K. 1 f~~CNt ~ N~MO~~ 1~~~~31 rp~ p~t~ W~i~f rN. ~4f 1 ~ . j~4iITS s. 1 k •Nov. 11~ 19~~.• BR01d~i~ Cfry, IOWN. OR ~OCqT10N Of OIwTN wsw c.nr ~rns rypSM1At Ol pinER WS1~iUilON-?~/U~ef ~u .:o~ wwe~, cro s~nn ..+a ..w.~e~ ~ fIfCY~ 1!! W NO ~ ^ F I3R0~•TkRD GE;dER L"EALC_~,~E'1rT'~'r~E- ~ FT. LAUDnRDAI,.. YES ~ • S1~tE Of t:[iM ~w ..o+ ~.s.•.. +•+e tItUEN p wMwi COUNiR1f ruRUED, NlvER ~tARRED, SuRVrvfNG SPOi1SE ~M wu~, cn~ n.w~.. wwc, tpw~~ ~ VYiDOw[O. Dni`ORCE~ ~ s?ttr~ ~ ~ ~~~u.~s~.~~ .NEk' JERSEY + U.S.A. ~•1•fARRIED B~R~K~FT ~Men wct.HO S[CUiitY N'uMtEe tiSU~l OCCUMiqN .art i.+e w~wa owi oueow ~ws~ w Icp~p pF WStt$SS OR INUIiStel/ ~•.~o. a w..w } OCCV!!!O N ~~M'3 U~1. hiN H~l~~~IO ~ ~~n~»t~. „264-02-566 ~ HOUSFWIFE otr*N Ho1'E t awussar~. RE5I~ENCE-St~t[ COUNn CI1T, 10WN. OR IOCAiION p'~ ~~m SiREEI AND NUwtsER IYlCqt f(S O~ MO~ ~ L""i ~~LORIDA ~~~BRO~r'ARD ~.~FT. LAUDE~PALE YES 101 S.VJ. 16th o~~ : fA1MER-NAM~ ~ui~ a~OMF ~ Utt MOIMfR-AUIOfN ttAME ~Mf~ WOOt! W~ . ~ CHRISTIAN WdTTI•iAN~1 ~ MADOLIILE RLOOI~; j IN!ORM~r~I-?JMnF AtA41NG ADGitE55 ' autn o~ ~.~.e. w~o., ar~ o~ ~or.., s•.n, to~ ,h ALBERT KEET ,n 3101 S.W. 16th Ct. Ft.Lauderd~le Fi a. , IIIRT 1. pEATM WAS UUSFD ~Y: ENTE[ ONIr ONE CRUSf 1f! (wE FOt o A?.'p i ~~a"~~ ~t~ ( ( b (bl ( 1) uii~e.. o..s~~ :e.-.~ ' w~ao~.n ewse te~ ~It~A-i0 -•e~~VhL F~41 L u rc't' . . , , M,ICNG.~:~: o h1t7~Sr/~7~C ~}nFN~chrt-c~Nn~~1~4 IN ~,iVC~ ~rr~0u7E C~ VSt to). pyE 10. q~3 4 CO~+SIOY[NC! p: sunwc ~~a VNPU• u~wc c.uu ~.s~ t~l ~OC-^~o ~h2C~NOMA- v F 5/~MVIp ~ (o~CO~t/ IART r_ O7MER SIGNIFKANT GONWII'.:MIS: COMpTOki ~OMtNYi1?1G ~O WM ~Yf MOT![lAttO W UYf! GntM M IAlt ~ bl MJ~OfST If 1ff5 r~a~~NCS cn- ~ ~~es o~ .w~ S~D![C 1w OQttru.~KG (~:St . . NO o. o~.,~ ~n V:~beW~l ACGIIF~~t. 9~sUDf OR DAIE INfURY ~rpa~w, w~, re~u /qtJR HpW INA/RY OCCURRED r[.nia w~wu or ~N~ve~ ua ?.~t ~ o~ r.ar u, cu. u~ lqwtK~OE; OR ur~EiERM~t~FO s~o~hl 206 7~ M_ ?M. 1lWR1I Al wORK PIACE Ot tr+/URT wo+e, r•~,., snin, rac~ar, ~pUT~pµ ~sntn o~ t.r_s, wo., an o~ ~oxr., s~~~[ ~ - 1SRC~rt ~~S O~ M01 O~rKt HDG.,fK. IS~K~ti1 7w. 701. M!- 'CERTMiUiiON- .~o.nw w• n.i ~ ra~m or~ ~tu ~no ~?s~ s~r whua une o.~ ~ oo/ao w~ r~f.r rw oEwiN OCCU~eEO .e ~.t r.wc[. e-: -~.e ra+m o~~ rtu ~oo~ ~nce a•nc ~~,:e~ c.•e. •~.n. ~c ~-z ~.s- •wrS~Curta . 1~rytND/D IM! TV ~ O~ r~ ~.~'.I~+.!'.liL. 1 71~. ctcuscc+ rror ~ p~ T ~tq 2/1 / th. l1/~ ~~d]~ t4. 3= 2~ M to tnt Uss! s s*_r-t~ ~ CERi1fKw1~`~-NE~~:wt Exwui~rt(R CNt COROriER: o.. r..e us.s or ~w ~wua w p.n. ~Me oet~oe~r ~.y rao..ouvuo otan e:...~...~w-r. w n.c wo, ..+o/o~ ~~e t.rts~o.rr~, r, aw.o.., raow w~ n.~ wo~~ ~ oum oeeoe.eo e.. e.e o.~e ...o ove w r~.e uvse+s~ sr.no. ir. ~ m- µ CERiIFtEP=N~tME ~nr~ o~ n~.~n SIGNAIURE ~?eci~~t q~~n[ OATE StGNiD ~rd.TN, o~~.+e.~~ J. H. H IRSji, ?~1. D. ,n L~ :k. 2/1 - "U`~"` ~'f1~-`~':"~~ : 16th Court s,•~~* ~.Ft . Laude rdal e Fl ori d si.~~ ~ 1~ r,. ~u. lURiR1, Ci.ENJ~T[ON. Lfu.OVAI fAtFi[RY UR CRE/+.A70RY-NA/wE ~ IOCAIII+N CiFf M 1OMN i»tt i; J 1 ~u~~N•~$E1~OVAL iu. ~~,HUi:`~'F'RDJ;1 CO. 7,TT~T~,~ T~' c~"~, i` 'y~~~i~i~`~,,) / _ 1V P Y~ _ .RJ~ rj 7i T~:~ DAiE r~.o~an, w~, n~n fUNERAt MO!.~E-NM+E ntJO ADD9fS5 ~ f~~~ft O~ h~ D. ~0~. C~t~ er ~ow n~~e. r+r r i ~ • 2/s_~~^ ennin~s 2211 Davie ~ltia.. Ft.~~.uderc~].e, rla. 33312 Y. S.f614 fUr~E~ Jv,i~CiO - .,r+~rL' ~ riEGi51RAk-kG.ti4lJkf ~u~ ~ r~ ~ ow;c ~[cc~vt~ ~r ~~ta? r_~~sua~ Rev.1410 t;. ~ +~aZ, ~Lc_ -4, ~-~-~.ziY~~C'~-, 1e~ t~- `t . . ` _ ~ . - - - CERTIFIED COPY ' ~~?~~1?~ . ! I hereby certify the ~bove to be a true and correct copy of the Local RegiBtrar'c record on file in the Brorard County.Health Departc:ent at ~ ~ Fort Lauderdale, Florida. _ , . • ~ ' ~ 7, r ~ (Warning:;~~ ~~A~~VA~i.~i unless raised seal of the $roward County Health ~D -_cl . - `r(,~~' ~~j~a`~t~t is affixed.) ,.o_ _ . -y 1, ~ . , . ~ _~~r t' ~ p _ PU T - '-.l~ . - - - ; • .o~ . ~r'^~C~v~ ~ - • ~ ~•G t fi? R , P ' .~',.1 ,,.o v ~ . ye_~ , _ ? ~o ' ~ ; : ~ ~County Hea1Lh Office.s~" ~n3 Local itegistrar = ~ :Fl.~A~O=~flAIF; . - ~ ~ . v1~J~ ~ ~ : 'F L O R 1'0'A`: ' y ~ . . _ ~ ~ , J ~~~....~~i•~~~ r 0,,~: ~ A. ~S1.~ ~ 3-14'=?~,~,,,,. - Deput7 I.ocal he~istrar c,, r ~ ~ ' ~ ~15 ~n~' ~ :~;°5 • - _ ~ - ~ ~ : ~ : ~ _ ~ ~ s _ _ . , . _ . _ . ~