HomeMy WebLinkAbout2933 ~ s b~_ CERTtFICATE OF DEATH 2~~~ t
:'•,•4 • Ikp.d.ew~ d Fie.l~6 .nd Ite6.MU~.ure ~..icY. ~ srwTC F~L[ No.
~e~c.,! ~Qe- nn~ata~~~rnr_~rni FLOHIDA
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itE~i16TRAR•s NO. ~
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c e t u t e d ~~UC~ OF O[ATN CODE NO. 2. YS{IAl R[f1O[IIC[ (1?~wr 1<~N /u~1 ~+~~ihtww Rr~/ser M)~.~ ~dw:~+)
+n 1 r 11 1 ~~N~ STATE ~i. COUNTY
ov ~,.cee St ...TOhns 6-~46 Fi oricia St . Johns
1 n pe~- b. C1TY, TOWN. OR LOCATqN K VUCE Of DEATN f. CITY. TOWN.OR LOC~TqN t. 15 RESIpENCE
¦nnent ~1NSIOE WTY UMITS~ INSIDE CITY l1r1~5~
rii~. St•A;~~'tiStine res~7 uo? St.~t~'? S}?ri@ res~
l. NAME OF ~ Ij w~r iw ~wyial, /i~r ~traet Ml~aa1 I. STREET ADD11E55
NOS?ITAL OR y~
IMSTITUTION 1~=:-~l~r ~~Oj~2l+.`3,.1 2~.J~~~`/c`~~ y,/rl~/e ~
3 NAM[ OF El'?at ViI1![ LW ~ DATE Mesl~ La~ Yt~•
n~Mw~•~~ GeorSe i~arvin lrier ~TN ~ecer:ber 10 1968 1
S Sf % 6 CQ:OR OR RACE ~ MANRIEO q~ NEYER MARRtED ?~~TE Of BIRTN 9 AGE (la /[o~ ~~~R 1 YW ~pEa t~ MK. ~
Ia~[ DVWq) lvw.w D~M Hwn lrN.
* r t c• i ~@ ~'1?'t?. ~@ rnoowco~ DiYOR[ED October 4, ? g98 'j~ ~
r 1~ 1 n 1~ ~a. USU~L OCCUPATpN ICi[a kiwd o/ roik bst 106 KINOOFlUS~ttESSOR INDUSTpY 11. OIRTHPUICE (Sfoft Or /ortyq counlry) 12 CITIZfN Of rtW1T COUNTR~t
. S t h pe r- Irrje/ ~oN e/ rw ( err+~ r~t~rt11 ~
¦nnent vT~.,l:ir~ce o~ t.~`ie . ea~ County 1eor~i~ 'JSA
Dlsc~' !nk ~3. FATNER~S NAME It .MOTNER'S MAIpEN NAME _ ~
t~pe~riter B~'i';.srier T~";~~"~r ~.~enfroe ~
16. SOCUL SECURITY !A- 17 INiORYANT A!/~tq ~
263 07 442 ',iary ~.Grier 21 5-,~'van ~rive St.na_Tustine F?orid~ ~
F un e r~ 1 1• CAYf[ O~ O[ATN (Eafa e~l~ ewt t~wt pn fi~ /hr (a). l~l. es~ (c).) V IMERYAI 6ETIMEEN
! dtreeto~ ?~RTI.pEATHWASCAUSEDlY- ~.te~~Y,iL"c.Tl~Y, {'i~ril?at~On L+_/~~~~MZ]1~
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co.~~,. y~?~. In : O - - -
i • i c n the rRk~ pre r+y to ~ - - - - -
S 1 o e w 1 ~Dasr ea~n (il.
~ r e,q 1 s t r ar atYUy !it t~~4r- ~E TO (el r(~ ~y. + 7 " Q ~ a
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• 1 C n 1 n 72 p pART 1~ Oi/(A $IGItlf1UNT ~pNpTM}IS COq"iRtR/flqG TO OE11TM SUi NOT RfUTEO 10 i11E 1FRYkf~~ p5(ASE Cd101T10N G1YEM IN IMT I(A) . WAS AUTWSY ~
novrs •f- ` rERFORMED~
~ ter deatb V . ~ YES? N6~1 {
or Defore ~ ~~b~a ~ ~
¦ n 1c 1 n •n H~ ~1b DESCAISE MpW INIJRV OCCURRED (F.wftt Adr?t e/~~jxr/ ts PW~ / or Ptlf O/ i/[w /A.1
~ 6 7 ~ ~CCIOENT wICIDE HpMKIDE
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tlon of
e O~). ~ TIME ~F IIOtl r S~ORf~. INI. j~lQ
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~ IO/ INJUIIY OCCURNEO 1Ar VLACE Oi INJURY~,(r. in a a~or! b~v, mJ CITY. TOWM. OR lOUT1pN COUNTY STATE
WMILE AT ~ IqT WH1lE ~ /`~A. ~~OI~. qftd. o~tt ~i1//.. rf:.l
~ MO11K AT WORK
~ 2i 1 ~ft~nd~d fhe dsu~ssd~o ~ ` ` , ro _ ^ •nd /~at s~w h~ ~Ii?s on ` ~ "
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D~~th occu~r~d ~t _ m on fhs d~ts ~t~t~d ~bo~s; ~nd to tA~ Mat o/ m~ knorld/s. /tom th~ uuaea at~t~d.
~ A 1 i i te~s jj~ s1ONATYAE ([lt/rtr pr Ip/t7 224 ApDRE55 22[, DATE SIGNEO .
ere to D!
~~~ytete k :~.S.:vorris ;jfi,nVi't.i:~;1!"a@~:~OT'I~~:. 1~-~~-~
~ a c c ur a t e. 2~ ~u ~~~T~ ~y D~TE 23r N~ME Oi tEMEiERY OR [REMATORY 23d LOCATtON (Cif~, (er~t. or ~oa~(~) (SY~ft~
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~ ti•`~ . j 612 j1. ~1NERAL DIRECTOII S SIGNATURE ADDRESS 2S pATE RECD. SY LOCAL REG. 26. 11E61STRAp'S (GNATURE
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