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HomeMy WebLinkAbout0418 . • ~ QEPARTMENT OF HEAl7H ANO REHABIIITATIVE SERVICES ~ ~ . . ~ . ~ . STATE OF ~FIORiDA Ew~eett S. Roben:, Secr~t~ry RerOie 0'0 Astew, Goraner = ; ~ DIVISION OF HEAITH . . . . . . w~i~ T. sowaa, M.P.H., o~~ta Alac~ua Count Heal~'n De artme ; y p nt TNepAone (904) 378•5321 P. O. Box 1327, Gtineswll~, Flotlaa 32601 ' CERTIFICATE OF DEATH Drp~.t.f«~..eLH~.1~6 .wd Rel~.bllu.~t.e Se..ke. srwTe l~~L[ No. o+~~~~A~TM FLORIDA Tr1E. OR ?RIHT IH ""~'~~'R'~~~7Ot° REGI6TRAR•S NO_ itlMANIlfT INK ~~5~_~NE rusr ~.~eou u~~ SEX OATE Of OFAM ~ ~ow~w, o.r, re~~ ~ S:E kAk0100[ FO! Msrr~aw.s _ Dona 1 d Ea rl D~r i s ke 11 Ma 1 e A r t 1 30, 1973 RACE vn+te. Ne6q. nreMUM ~Mau+, AGf-ust w+on ~ rrwt ur~ete ~ wr OATE OF lIRiN ~.oNn~, o~~. GOUNi1/ Of OEJ?iM ac. ~ s?eevv ~ ~~mw ~~e.~s ~ ros. wn wows rw. rw ~ . Wh1te ~5 a_ pctober 3 1907 Alachua CR1?. TOWN, O~l lOGT10N Of DEATM r.s~w em ~w~» MOSMAI OR OiM~ tdSirtUT10N- ~ w.~ n. enwe~, o~r~ snrn .w wwa ~ „ snurv ~n w_.a Gainesville Yes H_ ~Shands Teaching Hospital STATE Of NR7H No~ w ~.s.w_, Nuu QTR9~1 Of WMAT ~pUNiRY MARRIEO, NEVER MARItlED, SURVIVlKs S!'OUSE ~r vue, ane r?oen wr~ ~ , Oh io Un i ted States w~O~a r°r°e~ Ruth f/ ~ JSVU teSOe.~ce L q. It. ~tcusra SOCIAL SKURIfY NUM6ER USUAt OCCWATION ~e.ve a•n w+rwa ooMe ou~uw .~os~ p KYiD Of M15Y~ESS OR Y~DIlSTR~? ' u.to. v o~~rv { OCCVtN.D M1 w~uwo ure, eire~ u ae~m~ . . ~'~'w~... 6^n 376-36-1757 Ret i red -~cvmteit ' ~t}iDl.K[ tlW~S worissa«_ ~~pENCE-SlATE COUNTI/ GTY. TOWN. OR IOCATION ws~e Cm ~run ANO NUw~iEt L~~ ~ sncur ~es o~ wo ,N_ Florida ,p. Ma~atee ,k. Bradenton Yes ~~.4332 56th Ave. Or., East: fAiMER-NM~E nnT rbae Wr MOTNER-AtAlOfN NAME ~ws~ .roou uW ~ ` w'' . ~f . IS. ~M. t~. ~ ' 1 f0 T-NAME 'i@ 1 Ca @ O ~u?SwG nDDRESS asreea w~.r~. .a., cm o~ ro~. s+.+e, tr~ ~ „4 „ ,nShands Teaching Hospital Gainesville, Florida ~ ?w~eT n+ w uu ~r~ ~ ENtER OWII' ONf GUSE /H IM/E ~OR e, E ~ I ( I NL ~?'b kA Mnrtt« O..stt ~M ~e.n. ~ 11. ""'toun twYSt Cardiac Arrest . • - . ~oM~.~oM•, Acute M oca rd i a 1 I nfa rct ion ~rr~cw o~re nse w ~b~ Y ~rrea~~e e~~s~ ~a, q~ ro, w ~s w ed.uouewee o~: f~atlMO tN! YMYlM ?~~r0 f~Y3! lwft ?ART N. OTMER S1GNIfK/WT GONOIilONS: ~a~na+~ ~Wwwu~uO p eewa w~ rOt uu~nO W t~uf! Gntw r~ r~n ~ a~ AUI0151 Y 7ES r~n nwMwss eo~.- ~ 17!! O~ MO~ M~~~M w Mtf~rrn~0 GYf! Yes Yes m. ~ ~iion+iu~c, oe u~w€tE~iwuNEO w ~..oMr~, o..,.u.~ MOW tM1UR1/ OCCUR~EO ~e.we..+.~.e o. w,r.. n..... ~ o...w ~ M . : " 2N. 7k. M. l01. ~ INNRY AT WORK MACE Of WIUR~ ~r Mort, r•~r, snNt, ~wC~wr. tOCAiION 1 s~eo o~ Mo., an o~ fowi, ii~w ~ 7 ~ sreon ns w~+o ~ o~«et wna. nG ~ s~[c~n ~ ~ ?J~. 7M. ~1• CERf1fIGT10N- ra.rw w• ru~ wa+m e~r •~.r ~,~s usr a~w ww+/wa ~~ve o.. ~ or/ws w~ ..nr me oewrM oCtutN~ M~ ~4[f. @M M_ ~M~SICIAN: rO+M O~i rW WO~ wr/M N~_ ~wOW) ~~q. u+0, q iM NY ~ n.. o~ «neoi o.`,A r'i 1 1 1 T~~~. A r i 1 0 1 i~~ q r i 1 0 1 tu D i d ~w. a~ o:w ~,,,~',x`,:° i'.:, CERi1f1UTION-MEOKJ?l El[MY?+ER OR COftONER: o.. n.e us~s o~ n.e aor~ a oe•*~ ~~e otteoe..r ~ws no.~o~wus ow lua.w~~qM p rw[ WOt uq/O~ ~w! wvlt?K.wrqn, w nr prwpn, rO~*w O?~ ~!Y rOO~ Ol~~M OCCVMlO On M! W*! Ar0 CY! ~O TM! 4Yfl1f1 St~riO. { n~ M m- M ! CERtIHER-NAMf ~rrn o~ ?n..n IGN~TURE pte~y ~~we ~AfE SIG1rE0 ~.w*~. o.~, •w~ ~ - John Lewi s M. D ~ rn. -Cn. J~ n. Ma 4 1 ~ MnRMG ADOlESS-CER?iftER sueer w~_r.s. .w. em o~ w.r.. s~.n a Shands Teachin HoSOita1 Gainesville Florida 2~01 ~ Q 6UR1At, CREMATION, REMOVAI GfMfifRY O~ CRfMATORY-!l:1ME LOCJ?TtON on pt tpr.. st~rt • FccL~iit~ o Oh.i,o ~ /?e~»vcr,C :„f~n6o T eme~ ~ a DwiE I.wN~w, w~, *Wt fUNERAI M ME-NAMf AND ADOIIESS ~ sueu o~ s o uir G ~Orq, . t~r? ~y n~~ 2 ~ Gt~lls?QS F.H. ~ ~ ~ 5, s612 fUNER~I O~t-SiGy ftEGIST Q- ~/~''~~!U~Af~ ~ ~ /~j~ Dw~E ~t •v 0~~ tOCw~ srY ~ R w. 19 70 7sr TM_ ~C~Gw"r" ' ~~.(..Y.C ~ 7N Li~ ~ I I{E:tEBY CERTIFY THE ABOVE TO BE A TRLL A~'D E`CACI' COPY O~ THE DE~~F~p A`IU kEC'vR0E0 CERTIFZCATE FILED IDt THIS OFFICE. ST. wC+[ counTr FIA. ROGE~ ~u~TRAS r ~ , CLEnK C: ~C!~IT CCURT ~ ~ s_ sl ~3 1/ REGOR~~ Yf~: =1~D~_.~.~. Q'~+ O jl „/V/t,t~ ~ (DATE) MYR'f " TFO'h1ELL, ~cPUTY REGIST 6 ],'j ~ ~~3 V1~ w ¢ QIV!SIi;Y Ci AOVt!1fST~~l:~f SER7~CLS • D'V~i~7`I QF CCaRECi~G~S •!"I::'jh Ci F~M~:Y 1(d'/t`[S • 71Y:S~911 pF MEA[(M • 0~~~5~0~ ~f NEI1tAL NE~ITN W ~ C:T'S~4Y C~ PLAYYING AMU EYAIUA?i0Y • CIY!SIQ!1 C~ ~E'A'~~1It1Y • OIV~S~~Y ~~GL~TIOVAI REd~97UTAT19!1 • DIYISIO!1 Of YOYiN SE~I~ICES ~ f r.`, 1 ' e.,,. ~.~7 f ~ . - ~ . . . . _ ~