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HomeMy WebLinkAbout2900 ,~.~1''~ 8,1 ~ 2i'~~3;i~~ 1jL~~Q ~.h:~ ap p iT. VCtE ~:~Jtt~~1'tLl, ~GG~ ~ :~'TRAa Clf~r, „~-!~;~r COURT ~ RIPf~~ •;,f,~~Y . Fte 18 IU o~ AM'l~1 .1 a , ~r~ ~~~r*~` i t3 - _ • . ' ^ ' ' ` e~ ,~:J ~ - ~ V~~ i ~ ~ 4 yy t' t'~', ~ . . . .~i•' ; /~w.I.~ .r?r , , 3 T ~ • ~ • . ~ ~z~-- k - -bA~D$--fSO~~sP~, ' 'K' ' " ~ ~ , ? . . . _ . . r ~ ~ ~ • ~ • ~ DEFA~TMENT OF PUBLIC HEAI.lrH . . Mlt,.jON.S. SAS\.AMI, MD. MPM. ' 1950 N. W. FOURTlENTM STREET . - ' a~cta+.; ~ - ! . • . MIAMI~ FLORIDA 33125 ,~~~;r,'- ..--r ~ ' ~ . . - . . ° BY CERTIFY THIS TO BS A TRUE COP'Y OF THE LQCAL ItEGISTRAR' S RECORD OF DSATH. ~ ~ e~'~. .~.~~ta~~~u.~~ , _ ~:¢r;.;i~lA~ ZNG: ~E;;_ '`s~ ~jNot valid unless the raised seal DEP~T'Y RBGISTRA ``5~_ of the Bureau of Vital Statistics VITAL RECORDS UNIT ~ <<~;'*`s ~ ,i• ;~A~`~~;~~',;~~~~~`' ~ D~ADE COIINTY HEALTH DEPARTMENT ` ~ L~ 1 =•.~l 7~s aff ixed. ) • ~ ~ . v. •1, y . . ~,•:3 ~ ~ ~l ~ ~ ' . . MIAHI, FLORIDA y ~ f t~~ ~ ~ ;r~~~6' - ~n . ' - CEP.TI!~'ICATE OF DEA"S'H . ,.~..v~ : ~ ' _ ~ i)c~k~r~mtnl oI F1lldUtr#~Qt~wbi~ijati~~ ~trricec _ - 8TATE FILE NO.____ _ on~,~i ~+Fw~.n~ -F L O R I D A ~'~a~i~.r w~c.awmumnstas ~ . ' ' REGISTRAR~S NO. ' r :::CE~SED --N4ME ~~~i~ ~roxt ~•1~ SEX ~ DATE Of DEAM ' rO~~~N, D~~, I~if I t~lAE3EL M. ~~~RGt•i~~ t L7:t9ALI: , rdOVE:t~~Bt~R 25, 1973 ~•"E ..~~rt, NtGeO. ~rf~Kwn dOuw. AGE-iwSt o*wt~ ~ reu uaot~ ~ O•• DATE Of ~~RIM ~~+0•+rro. N~. ;COUNiY Af DF/~iN f~~ Ifr ~ ~!~~MD\~ 1 ~t~~f ~ .ql O~~S M01+~1 T.'f~a ~~F~~ 1 ~ ` ,.~;ii~~f. - ~ 70 ~-r-- k i ~~r~~. l~l, 1903?,. r1~~Dr. i iOWN, OR [OCAi1pN Of OEA/H ...s+oe ure uren HO$ryTAI OR piHER RJS~~TUTION- ~N/~MF ~u .+o+ urntt. .•i+t s~„~~ ~~.o MVY~(~ 1 s~eu~~ ~es o~ ..o ;:r:RTf~ :}IAh1I i,Y~:S Tt 10~5 I:. 121_ STF21:::T S'A ~ f OF b~RiN ~ u hoi u+ ~ s•., ~.rt dT11EN Of w'HAT COUNiR~ MARRIEO, NEYER MARitIfO, ;SURVfYNG S~'OUSE ~ rr wuE, ene ...~oe.. ....e , ' cowmr ~ wIpOWEO. DrvORCEO . srtc rr ~ I t:~,I:3E ~ U. S. A. t~IARRIFU ~71,LTCR C. RF:RGMl1?J ' - - - - - _ _ _ ~ _ - ~C~~~l SECURITY NUM6ER USUAI OCCUTAl1pN iuve er~o o~ r+ota oo..t o.w~~G roit or ~Ky~p p~ ~SWESS OY INDUSiRY +•o+saaa urt. ev[.. u nn~to ~ , U 04 0576 A ~ytiOUSti•IIFE (?Wt7 tlG:'4E: _ - - DEr+CE-SUiE CWNTr ^ Crtr, TO~. OR lOf~i~Or+ ~ ~s+oe on +~+~rs ~SiRfEi AND NUM~ER ~I zne~~. tei o~ wo ~ " ,,?~'L~)RIDA ~N U~'fUE ~~k f10RTtt t1I11t•tI I YES Z045 t:. I:. 121 STREI:'P - ~-.~;G -NAMF nnt ..joat - usr MOTNfR-h~arDMri~tief n•++ ~~oou i.s+ DD Y012l~I1127 - .f;EHRIiVG bL•'RT}lll tJ. CEi11SB ~'`tiJ~MANi-NAMF Mw0.~NG ~DGCE55 ~snur o~ ~.r.o tio. cn. o. ~ow.., s~.tt. ta~ ,::Ai,TER C. BERGMAN ~~n 1045 N. F.. 121 STI2I:L'Z', NORTH 1~IIN•1I, FLORIDA 33161 ~ DEwTH W~5 CwUSED Sr ~FHffP ('ul(1' pNE C~USf ?Et llt~E FOR (o), Ib). ~~i~~ •neou«~ ~..qnai ~l~Ml~M ONSt~ ~~O W~iM _ . . . ' ' ~ W~(Di~T4 C~41! . . ro~ ~~-!L~~i-Lt.--t t - C~'Z `Z~ i . U , •S ~ COHS[W! F G~ C~JM7.I~ONS. 1~ •M ~ ~ ~ ! :..vt ~~se ~o { Ib1 • ~L="W~"v L.. ~?f.~L,. G C.-~. .•..F~:•t! C~v1! ~n~. I . _~"__r _ _7 . _ . _ - _ 5'.r~~.f. ~Mf uNDt~- W! IO, O~ ~1 ~ CO.+StOVlwf .'N ~ ` . C~uSF t••t . ' • • ` <<~ ~t-~.(.C ~..c- ~'?-t C~ - ~t--: •r r ~ ~ ~ ~ ~--~<< _ =~E+ r, OiHER SIGN7iKANT CONDIf1pN5 ~o~.o~no•.s to~n:wr:v~ •o ~~.r~ wi ti0~ ~FU~lD W c~ult ~.•~er+ r.n i;o~ 1AUtO/SV IF 11f5 w[~e nho~n4s eo~ ~ ~•.~s o~ rw~ ~s+ot~ro u. onn+.~~~nr. uvu ~ ~ ~ ` - W OE•~n t t~C.~ ~ , L i- Ly~~ i. L-.. -~iw NO iw - - ~`_:blyi ACCiOEh'T. SUIClDE OR OATE OF IIJIURY ~..c•~rn, y~, •t~u F10UR ~ e.~rer u~ru~! ot n.~ut. ~a r.~t i M~~n n, wfr ~MOW IN/UR~ OCCU~REU -~~r':'~fiE, O! WaDE1ElM~NfO ~:.t ~.;.h~ . . . ~ - 76~ 70~ M ' )Dd ,~:;~RY Ai WpRK iUCE OF INJURY.7 n~..t, ~..~r, sr~~tt, r~Ctp~~, IOCATIOl1 ~+ret~t o~ ~ r o ..o, c~.• p~ r~«... sraq. Srl;~.•r r(SO~MOI 6/1~Cf~:OU.lK .y~fC~~tl ~',f ~ _ I ::ERT:FICATION- M~th D•* rE•¦ , ra+m D~. .t~~ •NO us~ S•w «y~(Mt~ avre da r q~/ero .w~r n[w n.~ D(~iH OCtUtRED wr n.t ?;•c[, M+ mt / r~-ru~ ~ ~ C~rf, ~..0. 1!~ eFF Nl~ ~ ~M.SlC1-N. T'O - Y6MTM D~~ 111~ ~tODf ~ttl~ , ~ f` _ ' _ rr1NDlD /wf ~ " ~ ~ / / ~ L ~ ~ ~ 01 r1 ~WO~w1fMil. Dut DECl~SlO s~Or ~ _ ~~1~ r ~ ~ T 7~~ 71/ 14 _~~"'j~t ~o *~e ~~asr-e. sr.~to ~ C E~~ i~'CwT~ON--MEDKAL ETAMINER Olt COAONfR ov r~t a.s~s w r.u »o_o or rt.r.+ i'~~ otc[a..~ M~S ~~IYRJ'f+~CfD Dl~D y'. O~ T`! l7D1 ~hD/O~ tM! tNViSTK.~'~OM. Yr ~.~Ir~~~r~, i MO~IiM U~I ?[~R "JJI ~ ~ i~.. a '__~~JFO Oti 1ti1 ~~fF ~ND DV! t0 r..f C~VS! S~ S~~tlD ~ . M ~ 77~ M ~ ~-c:~~{i v_N4Mf :nrt o~ t~wn ~ S ~t1RE - - oeorrr o~ r.r;t- ~--'OATf SlGNEO ~~•:~~ar., c.. •u~i JA."4ES H. STAGE, M.D. 'i r-~-s~ -~y ~~C:~'~~'s1" _~,k rroV._26 1973 _ - ~ ~•e-..~.~.~~GGRFSS-CFR1lFKR ~ yn ~ptl~ "'Ul1J~~IO~/+v SI~R 1104~ N. ~~6 AVE:IUE MIAMI FIARIDA ~3IG1 - ?~~:al. CREMATION, REMOVAI ~CE1METfRY OR CREMATORY-N~MF iOCAPtON un o~ ~o.... v.r~ ~ , REMOVAL - nsEVERGRBEi3 CEt~1ETERY Lt!~ i PORTI.I~ND - -F1AINE----- - ~"~~rE ~ ~ p+•M. O•~, ~(ae~ ~ fUN:RAI HOME-NAAtF AND ADDRESS St~l[t O~ o no., aT. o~ rown, ir.r~, t~?~ :iUV. 28, 1973 1~JOSEPII B COF & SON FU" L ii0. 1 I:E 6 AVE. MIAAfI, FIQRIDA ~ v~ ~RECTOR-SIG~NAiUAE R R- ~ afURf o~rE rt'~rve~~0 ~`~j ~FG~STt~I ~ ~ '~`-:i_c_ ~G 't'~ J i!!~J 7a f~OV Lr ~.7/J f ~ - - - - - - . - - - "I~rt"~ Tf l - ' r"~I F.:~E t~ LAW OFFICES OF EdWAR~ F BUTLER 93~3 NORTHEAST SECONO AVENUE. MtAMI SHORES. FLORIDA 3~~36