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Sn r~~- 0. CITY,TOWN,011lOCAT1pN t. K K~Cf Oi DEATM t. GTY,TOMfM.04 LOCATION IS ACStOfrKE
nc n t INSIOE CITr LiMITSt • tNS10E C1Ttl LIMIT57 r
r,~.. Ft. Lnuderdale res~ ?aQ Ft. Laudcrdale YES? MoL3 ~
~ t. NAwE OF iw ~pit~t, ~irt IIr~N N1rtNl lEM6TN Oi ST~EET ApW~[SS
~ MOS?ITAI OR ON A ~ARM) ~
°'ST'*"7'0" Lauderd.zle Beach Hos it.z ~T
Iirsa 3370 S.w. 17th. Street YES? rap ;
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3. NAMt OI ~/~f /UNNt LW 1. DATE Mw~A Dr/ Y~~/
«~M~~~~ HERBERT ERNEST P0:4ERANZ o°~~`?7N Nov. 16 1962 ~
S. SEx OOIOR OII MCE N~IIIIIfD ~ N[Yf~ MA11111E0? DAiE Oi ~IRiN AGE (Iw Y~u~ v U~.of~ 1 fWt If L~yR 2~ WK.
1Yf bi?t10~/~ X~+W Mr~ Hwr~ Niw.
" r 1 c. le White Nnoowco0 avoxcco Juite 6 1906 56
F 1~ f n l r 10~. USUAI OCCU?AT~ (Qi~t ki~1~/ra4 /~~e IOD_ KIN~Oi ~VSINESSOR IN0115TIIY II_ ~IRTN?IACE IShft M/~?tye tNtwt?~) 12. pT~tFi10~ ww?T COUntnlrl •
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L 2 a t i 1 nk ~A7N(Il'S N~NE MOTMER'S MAIO[M NAME 3
O~
~r~••~~~•~ Fredrick Pomcranz Martha Gilow '
IS. IIYAS OECEASEO EV[N IN U. S. ANMfO iORC[51 16. SOCIAL S(CURITY NO. A. tN~011 i f10NATYA[ n ~
I rY~ Y. M rvMA~ (~I M4 I~M !~I ~/M!~ ~ Mfil01 ~ 1 % ~ t ~ ' i ~ C',L"
No 299-07-9679 ~i~•~• 3370 S. W. 1 t St. Ft.I:audcrdalc Fla. ~
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_ er i y e n ove to c a true and correct copy of the Lo~al - '
Rcgioti•ar'~ record on file in the IIro~ard County.Health Uepartcent at ~
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_ Fort Laudei•dales Florida. . , . , ~
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(h'c~rnin~:. ?tot vulid unles~ raiocd ccal o~ thc ~3ro~:ard Cowity licalth - . CJ
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