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HomeMy WebLinkAbout1717 ~ zs5~: ti fILEu ~tt: otCUH0E0 =T.IUC~~ ~:o~MTr flA. ROCE ~`l~TAAS IN RE : Lot 11, Block F, Alamanda Vista Subdivisi~n, ' C~Ek~ c•~~ :+~~T GouRT Plat Book 5, page 49, St. Lucie County Public RF~~QL vf` ":s'o Records. (~T 9 2g ~'~3 26~i6'7~; . , . . ; , DADE COUNTY ~ . . DEPARTMENT OF PU~LIC HFALTH ' ' ; ~ MILTON S. SASLAW. MD. MPN, 13'30 N. W. FOURTEENTMI STREET DIRECTOR ~ MIA~iI FLORIDA 33125 • ~ ~ ~ . CERTlFICATE OF DEATH • [kp+rtwe~~ of Ileait6 and Re6a6~Nt~~~~e G.rkn srwTe Fac No. ~~~~~v ~~r ~~Fa~-i~~ F L O R I D A o~...,N 1056' !NT iNK ~p~uR'~~ REGIBTRAR'3 Np. ~ ~ECFASED-NAME ~~~st ..wo.e ust ~x OA~E OF DfAM ~ ~ort~, o~r, ~ . ~ Charlie Roundtree t a ~ RACE wwiri, w1GlO, wr~tK~M u.ouw, AGE -~•sr ~MOU i r[~~ ~..ot~ ~ o~~ DATE Of ~IRM ++ro~.rw, o~~, i~QUN1Y Oi DEATM / t~c ~ srecu+ ~ wrwo.~ ~ .[us ~ ros wa »ou~s ..w ~ew* ~ ~ ~ ~ ~ Negro s. 60 S, . Julv ? 2 1912 _ ` C~TY, TOWN, OR IOCATION Of pfATH wa~pe t~n urns Hp5?tTAI OR OiFiER NSTRUiION-NAnnF ~+ot en~e~, c:+e s+n:r ~rw ..uwte ~ S~Fi~~r rES C~ r~0 North Miami Beach Yes OSTEOPATHIC HOSPIT~I~_ -f_~_ ' _ StATE Of 4R1M ~ u Mot u+ u s•,~+•.~e C1~12EN OF wMAT COUNTRY MARRIED, NEVER MARdfO. SUQVrvWG SPOUSE W~~E, c~re auot.. r..rF ~ ~~'n* ~ ~ WtOC~wED. DIVORCED ~ sncr+ ~ i ~ Georgia . USA Married Lila Cotton ----1-------- • - - - - _ SOCi~I SECUtlTY NUM6ER USUAI OCCU/ATION ,a.t a~~o or wp~i up,ae o~u.~c rosT o+ iKWD OF 6USWESS OR ~NDUSiRY . ww•~.~c ur~, ne.+ u ~enna ~ ~~57-18-1148 Custodian ~~Dade Division Of Hos~ital _ RESIDENCE-SUif CWMV CRY, iOMM. OR tOCATION ~~s~ot un iu.rts STREEi AND NUM6E! Florida Dade • ~l.t~,.. ,FS o~ ~ - 0 a-Locka • No iATMER-NAMf nf~t rippt ~~st MOTHEII-MA~OfN NUMf ny~ ripp~E uit ,s Wile Roundtree Viola Unobtainable i N?ORMANT-lIAME /AA1l~NG ADGRF55 ~s.eetT o. o.:o . c:+. o~ s~.r~, n.~ Lila Roundtree ~~n 360o N.W. 20 Street 0 a-Locka ~ r~~iT 1 pEAR1 WAS UUSEO !Y ~fNtfR ONI f ONE CaVSf ?fR tlNf fOR (oJ, jb). ~NO ;c~j ~?no¦'~ut ttv•i ~fM(~M OM1(7 ~MO O~~~M ~rrfD~~T! C~uS ` n - - ~ ~ , v ~II ~1v 7 [ C ' ~ a ~ Y , ~ ~ • COMypy[~a:f O~- E COMDIt10M3. •M, ~ ~..E .,s. ,o l ,6~ c~~~ - ...em.rt uuse im. ~ p,;e ~o. o~ .s . co.+uoue..ce w - - - - s*..~re ~~e u..oe~- ~•~..c uuu usr 1~) ~~RT u OTHER S1CsNIiKAN1 CONDITIONS~. ~~af+p~s co.au~w~~e ~o oe•rn wr ..oT eei•reo w uuu a~.w u. ~~~r ~~,o~ AUTO?SY If YES +e~t •~NDINGS cow- ~ { ~~es w~+0~ LDt~lD Iro DlfE~r~r.uaG C~U1! _ %i tJ~ -L-~ L:C~ ~ / t~- l ~-t ' ' !t, l (-E ' f c .a.L ri! i~~ ~ ji~ iw ot " ~ ! Y"e s '^-oGah7~) ACCIDENT, SUIOOE p! DATE IWUQY .-.or~tw~ ~t~n ?IOUR jf yy IN1URr OCCURRED ~ tnie~ r.~ru~t Or iNlu~r ~w r~~r ~ O~ r~rt u, i*[r ; iqrarC~Of: OR IMIDfIERMI?1ED ~ ~ . i~~h1 xo ~ ~ M I ~ ~ ~NJURr wt wpR~c ~CE Of wnmr ~o~e. s~aer, r.cro~., ~p~AT10N ~ sneer o~ ~ r o. ..o , o~. o~ Tow.., si.n ~ ~ S~f:~~• ~t30~ w01 On'(F ~tDG.,F7C !S•tClf~~ ~ 711~ 201 709 CER7iNUT1pN- ..o..rw e.. ,eu .o.+rN e•. .E•• ~~+o us~ snw Mu~~Mlf .u~~ o.. i o~o/~~o rqr r~[Mr t~t OEAiN OCCUt~EO .r rwe ?,wct, o-. r„E IMTS~C~4N: ~ ! ro.+rn o.. •e~~ '~oo¦ .rn~ w.M irpw~ o•if, •w, w m[ ~[s~ •MI+OtD ME ~/y 7) T~ Ii 3 a ~ Z O~ r~ arqw~tOGt D~e l:~ O[CE~SED 1lO~ r ~ / 4! ~21` r `211 ~ ~U ~jl/ fVO~ Zit ~ f0 ME C~uS!'Sl ST~~fD CER1~tIUiION-MEDICA! E1IMA1?+ER OR CORONER o~ r~~ ~.s~s w r.~e TMF Di(EOttiT ~.s rro..o.,..c~o o e~... ~..vOI+O~ n~f ~4D~ ~~+D/o~ rnt v~reSnG•rqw. r. G~~..~0~:, ~ ..O~+~M o~. •t•t wo~~¦ ~ ~ OCCUtfFD Oa Mf D~tt ~wD DuF ~O ~M! C~uSf~i. S'•'~D - ' ::a M{17f M _^;R'ic~ER- m n~ r. S~GNAT E DfG~fE 01 f1Tl! TD~TE S~GNED ~..o.+r~, o~.. ~r.~~ - 1~___PR1'~~~ ~ 't~. ~l _~~k ~ ~r-- 72_ . _ Y4!~:!~v ~DGR:SS-CERU/Ki+ S:ifi' ll~ ~ I L NJ CIT~ U~ ~G S1~R 7,• ~ 'a ~~~~T - ~ EvP.~I, CREMAt1pN, REMOVAI CENETERY OR CREMAT01tY-r~ ~OrwilpN c~n o~ ro».. st•ie ~ ~ s•e.~n~ RPmoval ' Fort Pierce . F] ori~la ? ~A'E ow~, .tu. fUNER~I MOµE-N4Mf ~r~D ~ODRESS ~ snae~ o, ~ o.+o cn~ o~ To~+w, st~rt, tu ~ % sent._ 52~ .1972 n, McKain' S 808 N. W. 22 Ave . Miami Florida 14 ` ~~E ECT iU F. REGiS DwtE ~E ~ oCw~ is ue - : - a e ' ~ ~ ~w ~ - i~i~ ~ - -i " _ ~ n ~ ~;i ' • tl/ ~ • :a~„ , - ~ fia.l. I J . i~i~Il ' 7 : I.q . .~.j ' •n2 , - . rL.')At.il"F'-:.~. , ` ' ~ ABOVE TO BE A TRUE COPY OF THE I,OCAL REGISTRAR'S RECORD ~ ,'i";~~tt~t ~~~T__~'~. . - ; ~ - = , '.D~'g~!~i- d`. ~ - ~ ~ ~'p •t:` . ~1 ~ ~ Sg~'`~..A~-' Not.valid unless the raised seal of ` TY REGISTRAR . p the Bureau of Vital Statistics is VITAL RECORD6 UNIT DEPARTMEI3T affixed. ) C~ 219 ~ DADE COUNTY HEALTH ~ . I' B~Qx PAGE MIAMI, FLORIDA ' ~ - ~ ~ r ~ .~v _ .a_ . - ~