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HomeMy WebLinkAbout1858 U ~ ST-25,120 2sss~rz r' ~ ~iq~i~a~ac~s ~ount~ ~ealt~i ~e a~t+nent . P ~ ~ ~ . . , F ~E~AMO REC~IIQ~~ ~ i~.l E COUM 11 Fl ` ROCEA P0ITRAE ~Q ,~J',~~,, C1fRx G~~CU1T COUIIT GLENN V. HOUGH~ M. RECORb Y@RIFIEO oi~rco~at y 338 0 16 3.i9 PN_'13 ~ 2si5~z OTATE BOApD O~ HEAL7H CERTIFICATE OF DEATH BUREAU OF YITAL .rwr~.r~c• F L O A I D A ~'~'ATt FILt NO. B1pTH NO. RE(ff6TRAR•9 NO. 131 L~UC[ O~ O[ArN GOb6 NO. 2. YfYAt IIlf10tMCC(I~~Iw~1.a~n/y.d. f/t~..~:wa:wr R~:~wwMHn.1w:..M.) `°„MTr H1 h1allds '~5g-Y•R7C sr~T~ FlOY`1dA POlk ~ ~ Clit, TOYM.OII LOCATIpM t, 1S ~LRCE OI OEATN t. CITr. TOM~M.OA IOCAT1011 t. K RES~OENCE e Avon Park ~ s Or ~NO~ Frost roof ~ ;`~~N' J. N~ME Oi (I~ M/ y~~r, ~~y~~ ~/V~) t. STREET AOOREif ~WS~~i~l OII ~ ~~T~i°T~ ~Jalker l~temorial Ilos ~ita2 ~+1 Stanle NAM[ Of r~..r arr~~ t..~ wrE ~u«.u o.r r~.. ' ~i ~:`v°~++n FD!•JIY JOiF:~':i 1'.rLLY a*M 7 4 1966 S. Sfk ~ COt~M 01111ACE 7 NAN111E0 ~ 11EYE~NM1111fDO ~TE Oi ~II11N ~ RGf(/~Ksr1 ~~~~t*W t?1Mat~M[~~ w~oowco~ avo~cco 9/2/1a93 ~,~eMn) u..w ww N.... xw. ~!a le Cauc . 1G. us~~t xcu?~Tqw Irk~ l1~1 ~/rni N~~ 106. KINOO~ ~US~IRSSOU M~OVST11? I1. ~MTNI(It~E (.9dt A/~~R/~ tMM?~) 1. uruc~ or nur m~wr~r? Irriw~ weN w/~rati~/ l~J~, err~ IJr~flrrll Sales?aan ,rn USA ~7. lA7NtN S M~YE 1~ MOtNER S M4 IIAME . John I:el.l Annie Ch~rleswor~h IS M~S OECfAS(O [V(11 ~N U S. A11~[O f011C15? li. SOCUt SE[WI~TY Iq. U. IN~011MAMT ~ t10NA7Vw~ 1I.1. Y. VA1 (I/ M~• MN ~r/ M~WI ~ M~I-VI~ ~ ~i 3 Ivo 00-10- 2 41q St~nle -:;-"r ros t•cio P i~ 1~. CI1Ut[ OI O[ATII ~}_n/t~ ~~t ts~it pt~ liu (~l. lAl. ~e~ ~al.) IN7(NYI! St 7M'(fM /1J1T L f+[AtH W~S UUS[0lY~ e' y~A__ OlKET AND D[ N IMMfQ141[ C4Y5( (~I '~.Qr~ //~/L~~~ ~ _ , 7 ('atlillo+u.l/~~~. ~ OVE TO r ~Ir~ prt riK N - - ~ r~~~t (il. . . dyiq l4 •~Itr. p4E TO (tl f1~~~ t~~u lut _ O ?Alli 11. Ot~+[4 SKM/KINI COMDttqtiS COK~ ~ /K f0 OtITM hIt Iql R[Ui[C 70 ~T1K R~MMY~ AS~ COMp(IpR 61RR M r/Rl 1(t . MAS AUTO~SY ~ 3 ~ ~`t ~t~-~ rcRroeMCw • rts ~ +w O ' `?p• ~r•' • itob ascau wow uuu~~ occu~ao. fbs~a wrv~ ytiys.~ t~ Pot I r Pa~ II yY~ - ` ACC~DFM~ SUKIp( HpMKIM ~ ~ u o 0 -i 20t T~~E O~ l/~~r M~M~, lNI. 1'rp IMIVRr 'R. ' . o . i W = 201 ~M)U~t OCNM[O • 20f. i~ACE Of IM1U\Y (f. ~,~11 M I~MY~ ~fAl. 7% CITr, ~p1fM. 011 IOCAf q11 COVhTr SiAT[ - ~ wM~tt ~T ~ NOt W NlE ~ N~'~. /«~~r/. Mrnl, ~wce YI~.. rft.) • f YY011K ~ VYO?K ~ f 21 / rend t•~e~ ~~d /rorunM •ad luf u.? him ~li?~ on ? ~ D~~tAoccvr~~d ~t rn on fF~ d~t~ ~bad ~bn~~; ~nd ro eF~ 6~~f o/ m~ tno~I~Ap. /rom IM uuN~ ~bt~d i - ' 3a'~s1oM~TY~~ `/~Nt t ~jjJ1 App11ESS I2t. D~TE S ~O ' ~ , A . I. ~ G ~ Y G~C-f~-+...-.. dY-Y" ~"r ~`i e . . v ~ ~c`~~Z. ~ • Y ~ ~ ~jE~ Z7B. M/4C O~ C(Y[i[IIY Oq U[MAT011T 7I. LOCATION (CSI/. !Mlf1. P /M~1!/I (.Sfdtl t ~t.~`za ti~= IQ66 Bou ainvillea Cemete Avon Park Florida - ~ ` . ~~TQRE „ ADOIIESS 2S. y1TE 1!(CO. LOCAL REC. 2i. EG~STMR~S 51GM ~011E ~ ~l f ~ Avon Park ~la ul 6-1966 ~ ~~~J ~ ~ _ : ; . i f'', • .gr :.t J;4. •f•~ . ~ ~ t ~ •'~~~a~' . 7f' ~ ~ f ~ ; ~'s :y ~ . . x ; TI~.~CS.~.-~'~. ~opy of the certificate filed with the Division of Hea~.th ' in u~c~bi'~~~, Florida _ Q0/} Ry cn ~ ~'.~^~LJ ~~.Tr J(`.! ~E~L C~7o11217 ~18~~, . Regi rar ~~-~~__s_ r__.,.~ »~1_. r._ . . , _ _