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HomeMy WebLinkAbout2763 . 268484 CERTIFICATE OF DEATH (k{r~Iwnl ~I ~ler~l~ ~wd Keti~l.Ilit~lhe Setvk~t~ lTAT[ /II.R NO. ~N.~~«~, ~~~a~.,~~ F L O R I D A l+~F. OR ?t~Nt IN ~°wwruR`~'° REC116TRAR~e NO. !1~l.ld?iiNl INK ~CEASEO-HAMf nnt r~~ ~~st Sit K;'Ji00[ f0~ SEx DAIE Of OFATN ~ MONTM~ o~r, ~ ursnarars ~ EL_~ ~ - ~ R~CE .~«*i. ~w~o. ~W~K~M ~NOt~N~ AGE-i~s~ ~!+oi~ ~ re~~ u..o~~ ? w~ DATE Of ~1R111 ~ro.+~w. ew~. COUl1iY Of OEw~N t~c ~ fpt~r ~ ~~~nw~~ 1 i~a~f ~ rOf. My NOW1 YN. 1lA~ / . . Y~hite s. 59 s~ • CIiY, TOWN. W IOCAl10N OF DEATM w~~ ce+ ~rns MpSI1TAl OR Oi11ER NSIIfUT - ~v wot a~ enut~, wre s~r~i •w ..v~ue~ ~ . . . ~ ~ 1?fcw ~~s M MO ,1;~ n Live Oak ~te uwanne~ aua~t~r~ios~.ita~ STATE OF NRM ~ u r~Ot u~ v.s.~.. N~Y! 112Et/ Of Wf1Ai COtM)RY MARRlEO. NEYER MARRIfD. SIAVIV S~OUSE ~~Nl. o~ w~qe~+ ~u++~ ~ cowm ~ W~DOWED. WvORCEO ~ veunr ~ .,•~,b•~«• ~ New York • U.S.A. N. r,~' Louis,~_sehli~k n~~ e.a~o Sp~tA! SECURIiY HUINiER USUAI OCCWA110N ~ave ew~ w rw~ oo.~e am~o rwt w ~cwo of wsr+ESS at x+annr . c~~n~ ~.r~eo ~N MOMI~NO lM~, MM N NI~HOI r,t»+. r.~vt 17 Ih- 11~ • -.:t uron •"'~s"^'• RESiOENCE-SiAtE COUNi~ C1iY, TOWN, OR IOUTWN ~sae cn~r ?wm SiREEI A?M NUM~ER ! ~ ~lrK~1~ t!! M MO~ ~~T tM Fld Iq. Ik. ~ It~. ~ (N. _ MfMER-NM.f r~n~ r~oW i~st MOiMER-MAbEN NMAf rws~ rroae us~ 0 tf 1{ ' ~N101tMANT-NAME ~wRMVO AOORl3S ~ua~~ o~ ~.r.~. Mo.. cm p~ow... s~~n. tn~ n. S ~A ~ rA,~T 1 pFAiM WAS GUSf~ ~1~ f ff ONI~ ONf CAUSf /ER lME fOR o(b~ AND (t .rr ¦ir. t~wri r~~ 1 ( L H ar..~~N o..uT..w et~ r.reeun u ,e~ v YdY~ ~ r r'y'n ~11s/ s ~ Z~ji il, ~ ? M OY~ f ~ COwpllIONS~ ~l1~, S / ~~~c~ e•ve use io ~ (bl ~i~~ • ~rrfDl~t! C~YSI 10~, p~! ~ COM K! O~: ft~l~y0 TM! 4Npf~• I l\IMO L~V~~ l~St ~ ~ ~ ?~Rt N Ot?~EQ ?~e?~C~??+i t0?+Wt1pNS, no..s eo.xwm J~w,•. ~Vt MOl qU11t0 *O UY{! GMN ~M /Yt ~ a+ ~U1«SY ~F ~ES +e~e r~NO~..n~ eow~ ~1/ ' ` , `~~r/7 ' _ - ^ Itlf MO ~ I~ Y! fM OIII~YINIMO C~M~ ~L \ /id' ~ti N i~,~h.?.~ e'caocNi. wic~b[ oR ~~f3~J°- lU~ ~ rowtw. e~t, te~~ ~ HOII~ NOW IN1Ut1f OCCURREO a~wwn ~w r~n ~ q r~n n, mr 1 ~~,udE: ae urnE~csw?+EO l~ ~~.a~ tM. 7k M. MI ~?ilU~tY ~T WO~tK ?IACE OF INIURY ~t Mo+t, r~~r, snen, ~~cron. tOCAT10N ~~n~er w~.r.e. ~o., em ot roa~.~, sr~n r i sreon .es o~ .+o ~ omee wne.. ~x. ~ wem ~ , 7Ce 7M. CERi1FKAII~N- rONrw O•r t4~ ~1M O~t 1Ut u~T Mr' ~w~M(~ ~1 t pa ~ Ob/01Y~wOt mF/ 1M DEAfM OCCVNEO ~t n.f ?twct, O.+ we ?N~SKIa.N: ~OMM • ~00~ ~~tt~ 0l~M. ~MOL-/1 O~R. ~nO. M iMf Mtit I~~f~MD~b IMI T~ / 3 ~.~f~ W M\ [~M)'M11D0~. 011~ J~. o~cus~o ~ro.+ ~ L~~ ~1D V ~ 7" i~! Y III. !i~ ZO~. ro nH c.uu~u u~n~. C[Ri1FICAiION-MEDICAI Ex~k~~ER OR CORONfR: o.~ r.K uu~ d..e row o+ w.rn ~Ne o ea.n r•s ?w~w..cto w•o - I . 1/~rM~i~d~ d M! ~OOr /~MC/W fM! IMIl1tIGAT10M. IN r~ O~M~ON, Yd~TM M~ K~f MOV~ ~ DI~M p~CYlMO ON M! ~p?1t .Wp YY! q M! CwYfftS/ l~~tiO . t+o Al Cf11i1f1fR-NAME ~nR o~ ?~wn-~-~- ~ IGNATU ~o[c~t w ~ SK'~NE[' ~y+r w~o r~-~ ~H fiuqo_ Sot~~-~-D ~ ~k ~ 1 w~wqM+G ~OOItESS-CERtlfl(R sra~j w~.• o ~ - c~ w w+.~ sr~n • ` 5th & Irvin St. S. . Live Oa F1 0 f surtu~, eeenv~noro. ~MOV~t Cf/NE1ER~ OR CREMA~ORI-H~Mf IOCATlOM c~n M to.n+ sn~e ~ wran ~ Burial O' Brien Cemeter~_ r~uwannee Co. O' Brien,_____T1~L j DAfE irourM, oa~, vra~~ iUNERAI MOA1E-NAME ANp ADDfESS ~ f~~~n o~ ~.r.s. ..o., en~ w toww, ar•~e. n?i ! u(~~ ~s.. Daniels Funeral Home Branford Fla. v• 5. ~612 ~?~1 - illAit-SIGNAI _ o~r! uctntn ~r ?ow ~to~sn~~ R~r. 29T0 = t~ ;i tY. This is to certify that ti~is is a true copy of this. certificate - j ` -'J • ; as it appears in the files of the Suvannee ,~~'~;"He,~il'tt~- Dept. ? f E'j`~~, - • ROEO ' ' ' AND RECO r•'': ~ ; -~i .,"r ; , ` fIl.EO , ; ST. WCIE ~Pd tRASU• 1 • ~ er: ~ CIERK E'.Glltt C~URt l~ j~` Po1}ittBQ ,.i~~. RECORD YER`~IED . ~~a ; Ri~iatrax~ ~ ; ~,~3 : y. : : : ~ - ~ ~ ~ t5 11 a+ , . : ~ p~ . , Z : - 268484 ~ ~ r ; . 6o~K r ~6i ~ 1 ~9 '