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HomeMy WebLinkAbout0490 _ . t.~/ ,.srd I..:.:u? •r,- ,~-~F ~ ry- F~tc ~o. _ _,cICAl~: ~~=~~1~ . ...::~c_.u oi Yiial Siatistics Registrar's \o. ~ FLORIDA i':«.l:E OF DEATlI•,rj ` USUAL ItFSID'L\CE OF DSCSASF.O: . = / . , ~ • C.avnV ~ ~ ~ ~ ` - - - - Dis.riet Xo. ' . . _ ~ - ~ ~ - . • I~ ~ (a) Stal~ . (b) OouaV.. - ' ~ . i'ttcint! Ptecinet N0.~`y ; - . ^ (Wtitawme.notnumber) CiVor / fi (ej CiV or Wwo~--' /,-J' • , . i ~ Cayor.,~-. Ili , - :.~w n • • - - - - . Toan Na ~ - ,T! : ~ (it outaide eiV or t~o.rn Lmi~+. ~rriu RUK.\L) ~ t - - ' tl , , , ? ~ fY ~ ~me ot hosvital or insti:utioni ~ • , . • • ' ~ • , - - - - L'~ : - _ L ~ J ; ~ 11[ not ia 6arviul or inttitution. write ~trcre aumber oe tocatiao) (d) Street \a ~lt ~r~ _ w 1.ca~th of stay: In Lo:yial oc tastitution s r. ' . V• h T ti.~: cummuniw I-~ . ~ ' (Speei f~'~1+eryrara.mua[t..o: ~:afs) _ 2` ~e) If forcign b~.zn. Iww loeZ in U. &/1.T ' 7~n ' f _ . :':'t.L. \.ftSF. OF DECE.~SED ~ ~ it reuraa. 3(D) Soeial Seturit7 . ~ lIEDICAL CSItTIPICA?IOH ` f # name arar No. " 20. Date of DcatL: ]donth - D~ ------r- . ~t Ycar ~__taurv Kiont~ ' . ~ S. i " ' ' ' _ - - ' - - 6. Coior or r~ae ~ . j' 21. I hereLY ccrii[Y tLat I~ttendrl tLe dt~oca~ed froan _;in.lc. n~zri:J. w:~Sow'd ot ditorcc3 _ / r~ _ ~t~l ~ 19 `.,_:To ' 19- . , .a~ I: nurricd. wi3oxcl os, di~oroeJ. ,Lu~b~nd of/ (ot) ~ ~ • , . . 19 ,_i i - ~i that I last ss.r e -"ali~~ on _ , - rf , ~ r: viie of ' r~C. ~ and tLat dcnth x:urre3 oa tbe ~L/e ?rd bovt ~Lted ab~se. Da~~ueo ' d~e of hu+Lar.d or ~i(e. tt L T~ar: IQ,ere.:.zte ceise a[ 1.atb ~ a , - " ~ . . ' • ' . : ::.rii~ .:ate af dccc~ced > ~ ' ' " ~ ' ' ~ - • i Imoalh) (ita7) (Year)' !i ~ ~ .1~r: Ycars Yont'ts Da)r+ I13wauunoned;yr ~i Duc to '-~'fc t _ i- / ' . . ~ - _ ~JN y ~ 1~( L~ Q h~ ciin. Dce to - - . ~ 1:irtLr:aa+ ' ' ' Ot2ur oond:tior.s ~(C:ty, tur a or eount~) iy~u or fureua c.~a:wL+) (Inc';.3a yr ~-naner ~ritAin 3 months ot dath) . .,.uaS oceuDat'wa " ~ ` *f.!:i. _ +:.tajo[ f:adir.zs: irr o- Les.n~a I L~erliaa ' - ! of c. craticca tLe eaux u ..une F . . - - ~ r ~rhi:h de~tb - ^ _ . : ~ tGirtdatcofoperati~n) 6 i~bould be ~ : i. ::ir:l,.iue - ,clur:ed st~- ~ - . a( auw:sY iistitali). . - .1 3i::i.:-.n mrne i:ir:T.J'scc ` . ' . - r~ ~ 1 "r. 7C dcac}. Laa Sue w e:tcrnal caaaca, fi:f ia tLe t~.llovic¢: fy' . S:.forn~an:'s Siewtute ~ ~ _ - - ~L~ ~CLi:3t SUCGIIt. F.om:c'~.e (~Deeif7) . \3dcc•s ~ . . • ~ . ~ . _ • " lb) Da!c'.I ct.arrrnce _ - . " ~ • : iel Y:o.~re dSd ini~~Y ~ccu[! _ ~crial. crmiati.in or removalt ~ (CitYurt.,wn! i~unt7) /3Ltaj ~ ~ ,"v' _ i' (dj Lid 1LlYfy ~.eeur in ot ~i..~ul L4mo YIi fuw, ia iudm.trial P~r ia (r) Date ' . ~ 1T (G) P1aee - - ~ ~ . \ ~ ~ ~ _ faLiie D'ucrT c^uoerrl Dimtor'~ S:zoau+re - (SV~e+tr ty;.e of L:acr) . :a (a) Addnsa \:'6: < a: w•~rk2 Ie)~ ~::~a~:.aof in3s+r1 . _ . , ~ CS. b..:za~un ~ ~ - - - .V. D. 'rilcd _ - _ 2? - - . ~ ~n _ - - . . ~ ' f ~ l..:a: i: w:~u... ~:.1 :.aor...a ~ 1 ~ IIata J:~cJ - ~ / Lf0 AM~J RfC4RDED f~. LUCIE ;.OUM1Y iLA. ~OCf ~ ?4~1RAf l CIERK C;~c~~r ~~,~T~ 258485 1 hacby aeriffy thb to be a tru~ and corroct copy ~ fhe (,o~( ~'fCORp YEPit IED..~.......~ Ragishcrs ~ooord on fi!e in tht St. Luds Courtty Ncthh Oop~t~ ~,Y ( O V S~ 11~7 ~ : rr+aM at Fort Pieros, Flortde. YfR, s ..,..~~~.~~w.f~.; TY~-~~ ~ (Waming: Not valid unless raised se~l of tfie St. L~xfo j 1 1 1 y. 1',' • county Heshh Dspanmont Is aditxcd.) _ ~ ~ ft a , 'r J, • sY~, ~~ti~y • . ° tV. D. MILLER, Ri Q "~':~',~d+. . ~ ~Otslfr 11e~ffll OffiCat tc ~rs[ - Y ~y.' , .c. ~s _ , . r ' ur ` ~ ~ ~ ~:`Ji •~ti'~" •4r~~0~'•' ~ . ' ~ Gq~str~ ~ ....•-;hS , ~ ~r, tt ~n~ ~ . $OC~ ~~U PACE ~ } ~sa~ a' ~ i ~ ' ~ r ~-'~i' ms:~~-~~u~ ~~'"~'r.'-~„_.... . -~--n-`'.',..~-~`.+`z~~'+,.f?'~'~~'~~