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HomeMy WebLinkAbout0984 . 258801 i CERTIFICATE OF DEATH QrpaAwew! ~i 1 kalt6 ~nd Re~al~il~~~~t~e Crrficea iRAT[ FIL[ NO. } iw~ nxw or nr.v m F L O R I D A ~ t~?( OR ?tlNl IN ~°~~`u~~"~° REGI6TRAR'S NO. rt ~in+~HlN1 INK OECEwSED-~f ~•s~ SEX Cw1E OI Of~t~f ~~o..~», o.r, ~ ~ St} Mth0100[ FOf ! i ~5~~~~~.s , HERBERT C. DAY tbIale ~ Februar 1 1 ; RACE ~U. wl4W. ~W~K~N ~rour, AGE-a~ft ww~ ~ nu u.wl~ ~ o.~ OAiE Oi NtiH :+O~~~w, o~r, CQUNIY Of DEATH 7 l1C. ~ 1ryCM11 ~ N~twa~~ Il1~~11 rpy. p~y MOV~! rN. Tiu ~ + tYhite 8 k ~Au .12 188 Broward . CIIr, iOMM. W lOUT1pN Oi OEAM ws~w c~n ir~n HpS?ITAI Ot OtnER NSIIlUT10N-NM~f ~~r ..o~ u+ ~in~e~, cro s~re~ .+o ..w.~e~ ~ snun +es o~ ..o Hollywood Yea Memorial Hos ital ' STA1E Oi NRM ~ u NO~ w u.s ru~ GTIZEN Of WMAT COUMiR1f MARRIEO. NEYER MA[Rlf~. StJtVIVNG Sr'O!!SE ~r ~rw. Gne woeM .urt ~ wbowco. onoRCEO None ~ Illinoi s + USA Wido e~ +.~e~e o~ct•sto 5«~~ ~~uRli11 NUM6ER USUAI OCCU?wT10N ~wvt awo o~ ~.wa oO..t ow+~+G .ws~ w KYiO OF WSWESS OR tNDUSTRY ~:.to r "vl~M eccvueo w ~+o~ar+~ ?ut. mw a m~uo ~ „ pg ..p ~ 2 Auditor American Can Co, us.ot~:t HWN ,o..~ssa.. RfS~DENCE-Si~Tf COUlAV dri, lOw1~1. OR LOCATION e+sae tm ir~n SiREEi AND NUM~ER ~s.ecN. ¦es w no Florida ~p Broward Holl ood Yes 2300 Park I,ane fwiNFt-rlwiuE ~~n~ r~ow us~ MOiMER-~uDEN ?~~f ~us~ ..toa~ us~ ~s Charlee Da ~a l~oore INtORM~i-w~uE ~tAlwG ADG~tESS ~snte~ o~ ~~.o..a, cm o~ w..., u•n. rr~ Martha Hainee ~~•920 N. rd. Ave. l~a ood Illinois ~ ?ARi pEwM WAS UWSfD tr: ~fNtEt ONIY ONf UUSf IER l1NE FOf /o~ (E~, ArrD (~N ~lTYII~M ON e~ ..~o a.rw ~ r..reua cwae _ ~ c E;~ 2 9-~- ~~v ~ Gv ~,d~2 ~ c~ D ' thi J QS ~ ~ • M ~NC (OMOIIIVMS. AMt, . Q~Y~ ro -~-p~-i a Sc.L R/L. s: r S ~rr~M~t! c~uf! ~o~, pyt t0. O~ .3 . M~SlONKI p= . ~~~tIMG 7M~ YMO~~- ~itMO C~YS! \~ft /~1 ~ OTME~ SKaMIFKANT CO~'NMT~S: COMO~TpMf CO~RWIR~MG ~O Of~M ~~?I NQi lfVllO t0 4VS! GNlN M I~tt ~ lo/ A~~Sr IF 11ES r~f~ /IMOIMGI COM' ~ ~ IRf p M0/ p OW~ M1fWIMIMG C~YS~ No y.~1~ t KUDE?+t, SUK Ot A ~~a+rw, p?r, ~e~e ~?IpUR Hpyr ~N1Ut11 OCCURtEO ~ t~~ a~wi~n ~M rur i w r~n u, mr ~ ~~qMcp.pE; OR YrOEiEUUr+ED ~ 9D0 M Mc M 7M E IWUR11 AT wO~K ?IACE OF NriMV.* ~o.e. r•~.. sra~, r.crw., IOCAilON ~ u~en o~ e.r.o. .+o., c~n o~ ro.rw, u•n ~ ~war. nsw..o~ o.r~a ruc..e~c. ~sncr.~ 7w 2M ~ CEtTIfKAT10r1- ra.*w we nu .a.M w• •e.~ ww us~ s.w wr/~u~ une o.. ~ OO/D'O MOt ~tlw 1M! OfA1M OCCYt~EO •r s~e ruce. a. u~[ rn~s~c~ww: ..wa w• nu wo. ,rn~ oe•w~. ~wow ~ o.n, ...o, ro ae ks. .•ne.aea r~e I TO / a p r~ c..o.neoot, oue ZN. O[Cl~StD ~Wr ~ V ~ l tD 2'~1~72 fli tU 7~J J• r tl~ i 4? M. ro mt uuse~s~ sr•no. 'i CEtT1fKAT~O~+-w~ED~Cwt Exw~wEf OR CORO~+ER: a+ ou us~s or n~e wow a oc.a~ n~~ oeceoe«r ..s r~o.ow.ceo ouo j eLUw.tp~ or Mt q0. .W/W TME rhesrw.~~, eu r~ O~~~q~+. , ~M O~r RY 1qY~ ~ M~tw OCCYIllO OM 1~! 0~1t ~MY WM W/Mt UYSl~L St~RO. ~ ~m M _ i URTI)f1E~-w~f m~e o~ S1GNAIURE- [ nt Aif 51GNE.yO ~.~OM+M, w~, rf~~ f t7~ / ~ ~ C /}v~.l ~ ~ • ~ ~~~.1i0 ~ i 7~. . ' tk_ i - ~ ~ ~ ~NYwG A00lESS-Cf~iNif! ~t siaE~ w~.r o. ~+o. cmr w w.+.. sun ia j tL ' ~ v~~ //y?c7a~ ~7Q ~ j 'Z'"~ ` {~u~, CREwu(ipr.~, ttEwipvAl CEMETERY OR CREMwTOR11-N~uwE lOCntiON an o~ to.r.. ir.n i ~ vec~+ ~remation :.Ro al Palm Crema 2~ Pom : OATE ~.~o..'.. o.•, ~e.~~ WNEtwt NOME-NwiuE ~wD ~DORESS ~ snen o~ ~.r o..o., un o~ ror.., s~.rt, i~r ~ ~ebruar 3 1972 ~6adlin ton B ~c Coo er 140 S.Dixie Hw .Holl F 4'. S. ~612 ftME WRECSOR-SIG!H~fURE. REGISTRAR- wf I ~ OwiE lECEi~EO ~K+OC~? REG~SGf~w~/~. ~ n!'v. 1970 tp l~ ~ ~ t~.l~Z.C~/C~ tM. f//~ Tw ~ ~ I C - . CERTIFIED COPY ~ ~ I hereby certify the above to be a true and correct copy of the Local. Registrar's record on file in the $roward County Health Departrr.ent at ~ Fort Lauderdale, Florida. ~ _ - i~~8~. ~ ~ (Yarning.__ q~~.v id unless raiaed seal of the Broward County Health :3 ~ ' pa~~~ is affiaced.) f~~fp !v~ °.ECOROEO . . ~ ;`vv,• TY FL . ~ _ ST. IUCi[ :.OUN , l ' ~~~UT T • , ~~Y4~ i~OG• f 0i+~~45 ~ V, ~ ` ~ ~ s r CLE".t C, ,~UIT CQURT _ tt~G: _ tt : . ~-v~tiG~~c^^~~ ` ~ ~ _ _ ~ ~ : - ~ ; ; County ~iealth Officet' and Local r~egi~~a~ il lg ~73 ~ - . : t t'J;' L ~ • F`+~j ~ : • , ~ ~ : i + a~ _ ` '~~~`1C% /f ~ n ! . ~ l , - . ~~j~ ~ ~ ~ ~C . • • ` , ~ ' . ~ 2~2~,T2 ~ •'r~ ' ~ ~ . ~ . Deputy I~ocal Registrar ~ • - ~ - ~ ~l ~f ~ - = Y . - : ' 4 . . . . . : . . _ ; ~ Yx_ y~~ ~ ~.us: ~