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HomeMy WebLinkAbout1956 / ~ POLK COUNTY HEALTH QEPARTMENT ~ ~ WIll1AM f~ MILI. JM..~ M.~• _ . ^ _ _ ~ . _ OIRtCTOA ~r~.7tf~~ ~ ' ` CERTIFtCAT6 OF DEATH - . ~ - . . . ; ~~ryrtlwn~~ a~ ~ 1~~~1~ ~wd 1tely~.l~llwll~e $e~rk'e~ tRA7E FIL! (O' ~N~IWw~1?~lf/?~~1 FLORIDA RFGI6TRA~~ WO_ w,~a.~ ~ we~a ai • 1 `y OECfwlfO-~+~E ~•~s~ ~~s~ ~t UwTE Oi OfwtN ~ +o..~w, e~r, ¦~u ~ r+ e ~ ~Tack L. Freeman : MatP ~ i~a~ ln 197?. . - lACE ~~~f. r~cq. ueMt~r nN~~~, AGE-t~t~ v~+q~ ~~e~• ww~~ ~ wr OAiE OI ~1RM ~rwaw. o•q COUWI~ d OtAiM ~ ~rc. ~s?uN~~ ~4~n.~~. .'w~. w.~ .~w•~ ` ~UZY 19 ~ 1 RR7 n POZIt ~ r o :s t:hite ~ . ~ITII. TO~. OR IOCATIOrt Of OfAfM wtyl un ~w~~t HOSNIAI OR OiNEt INSi11Uf10N-NIUME ~N no~ ~M ~~M~, 4.vf 1~N` v' ~ ~ CO fltCNt O\ w0 tw C7 ~ . LakPl"and Yes „ Likelancl ~,enPral Ffos . . ~ : n gtwTE Oi MfM .u wo~ v f~., w~rt UTIIEN O/ WNAi COONIR~1 r+Al1~~E0. HErER MARR~EO. SU~VNWf'i S~OIISE ~~~f. bnt W~+~l~ pC '_3 COUr.~~~ WI[KIWfO.WYOK~~WCr~~ ~ :~c..~z ~'~oraia ~ i~.S.~\. `:arriec~ Mzri.? E'.. z.W Y_) ~ - _ - _ _ _ _ ' O Sp~iM SEC4„n? Nl/WER USUAI OCCWA/1OM ~GV~ ar00~ ~O~t OOM! OV~~+G +~+17 O~ tMaU OF WSwtSS O~ t?~OUSIfv oN,.~A ~ ~ .o.a~..c~w~,~•a•u.~r..~~~ Notel F1UGL~Or = ~ r~-~ ~ ~ ~ 265-22-3970 A,,, C. P. A. a It wy~e c.o iw~n SfREEt IWO NUM~E~= ~ • ~ ~ESWE~+CE -St~tE COUr~1r C~1y, iOW?+. O~ lOCwt~O?~ _ y ~s?~a•. ~es o~ w - Florida ,Nliiqhlands ,,,~von ~'~.rit ,.~I~o ,;.'.t.2. 8ox 5 7 A uSr MOfMER-AYIDEN N~ME ~•~t~ ~wp! ~s~ . ~ M(NfR-NU+F ~.n~ iiOa~ t:nknown [Inknown ~ ~NFORM~wt-w~f ?u?lu+G /?OO~ESS ~s+ne?o~ a.~.o...o.. eer w wr.., u.n. w~ ~ ~ ~ ~2arie B. Freeman ~n P,t . 2 Rox 5~'7 A Av~n Pa:. :'l '~R~~ ....o.~...~. Iw11i OEAt11 WwS GUSEO ~EnIiER OHIY OHE G?IiSE IER lME f0~ (d~ ~?'b kN ~eR.etM o~ser w•*w ' . . J 1~. r.~a. _ c~rs~ ~ . ~ ~~-L LL J.• LU L LL L~L.~.'~~' LGt.~sfi ~ , . . ~ ` ! . ; % ,~o G.c~.~ cowo.no»i....Mr. /~I. ~i .1LCWL4 li ~if.'~ t3 ..r~e. e..e ~~s~ ro 1~1 ~ =L~G 1 ~ _ ~ ~....en..re uwe ~o.. ow ~o. w•s. e+~or e w~ i J ~i~t~MG tw~ VMP~~- .i.,~./ ' ~ { y--; ls~.~o 4uu ~~st ~t~ / \ ~ ? / V _ . ; y ilf C.J~.ti wUTO~SY If YFS ~+~~e ~~~o~..es eo~- :.F ?wtt n OiNEt SK,N~~C/WT CONW11Or~5: CO.~O~npwS td+~mvtu~G r0 OE.M W~ ~O~ ~tt~rf0 ~O UvSt G~+f~. ?..r ~ a~ tteS o, wo, rae.fn o. o~re•.~~~»o ewse ~ ~ ~ o. oe.rp ~ ~ ~ C~,~.!.~L G~i. ? L c_ L.. L ~`-i ~ y.eboSi~l wCUCENT, Sll~f~~lE OR DwTE WN~Y ~ ro~*w, wr, ~e.~~ ?~OUR HOW IHIUR~ OCCURRED ~ e.rte~ ».nin o~ ~.u~~• ~.~r ~ W r.r* rte. r . ; ~~2 Hp+MK~6E: Ot W+OEIEWWED ~ "'M ~ 20c. M 70i INJU2~ AT wO;K r1ACE OF W IURY wo+e. v~ter, r.[+wr. LOCATION 1 snfn w~.~ o. ..o., Git O~ ~OMM~ u•~e ~ ' IfIfC~~~ nf O~ r+0~ OMK! MOG.,tK. tt?KN71 r' ~p~ 70~ rp.~tw M~ 1f~~ ~~M 6~~ 1!M 4St yA~ Mriwf~ M~! OM ~ aO/OW ~+Ot +~h+ M! OFwTM OCCYi~ED ~1 Mf ?UCl. Oi+ ~w! CERTIF1CwT~0?~- ro..u~ w? n•~ ~ao~ .~~e~ oe.n.. ~.,w.~ o•n, •.o. w n.t ~eN - u - ?N~SK~aH: i0 O~ r~ a.o.n10Gl.OW i~r.e..ato o-e tq Uc 7~1 t4 M~o n.e ewuu. su~~o. )1• Dt[l~HD ~~0+ ~w! DKfOtwi r?3 ~~~~CtD Ol~D C:Ai~t~UTtOn-MEDKwI Exw~wNER O+ COiO?+ER: o•. r..e ~.vs o~ ~~r rou~ o~ w.r~ r,, o~~_ 'e•` "O"¦ ~ r ;p ~~u~.ii~Ow W ti! ~00~ ~iA/O~ iw~ Mrtlt4~~~Ow, aa ri W~W+. - r ' _ r~ ~ M Ol~tw OCCV~~!O ON Iwt D~R I~MO 011! t0 tw! C~YHtS/ fl~rlO. U , C. J M_ 51G~TIftE _ o~es~r~r.t GATE S+C,?~EO ~+o~TM. o~~, rtu~ CE~lT~hER-r~M~E m~t c rn..r - } 1 C f~: 7~. I~ ~ ~ __~..7 ~ 'r~~- /('~N_ ` 77~ r~J_'` • f i ~ ' ~~rltt r p..r0. C~t+r Oe t7.rr f*~tt t~• ~+uu+NG wDO~ESS-CERfu 1 / ~ ~ " r ~ _ ~ C~EtE1lY OR UEMA104'~-ro~a~E IOG~i~ a p"" a~•rt ~~ata?, GtE~Tqw. REMOVnI ~ s.eur.. ~ 3urial ~3ougainvillea OwTE ~~o+~w, q~^ ~ 2 NNERM MOME -NA1NE A?'ID AflDifSS ~ sneer o~ ~.r.e. ~.o , an o~ ~or.., s~•+e. F Ia • 33 ~ 2~ 7„ ~:av 15, 17 nhora~n-Smi.t~Y~ F. H. Avon Park, ftA+ERAIDMECtOt-SK~~~u~ / ~ iEG~ST~ ~5/GN~fU n DAtE lKt~vED ~f IOCw~ ~fG~lit~~t /y,~, ~ / ~ / ~ w . i l~"^/~? ...K~ 7N 1!' ';Gi.7 ' / ?S! 1~~~ ::ereof certif~ the above to be a true and correct copy of the Locai Registrar's record on i-~ tile Ofiice of the DMSION OF VITAI~ STATIS''i'ICS, at the ~'OLK COUN`i'Y HEALTE DEP~.~I;~?'~iT ~ f'~:PF''r.R HALr~i, FI.ORII~A. ` . . .~~1' `~-.i . - ~ - , ~y'_ . 6 ~ ~ ~ i'r ~ ~ ' - , County Hea1fi~}: Q~~icer and - _c~l Registrar ' . ~ ~ ~ ' ~ . : _ • r ,E . ~ ~ l '`{j PutY ReSi.atr3r _ ~ ce Issued i _ . = : ` ~AL:.; ~ : . . ~,1 ~~lG: Not valid Zm? ess raised seal of tti~fDIVISION OF VITAL R gTISTICS, POLK COIIrtTY ~ZTg ~p~l' is aff~ced, 800K PACEl956 : - - ~ ~t_~r v> : - - - - - - - - - i s-~ I~~ , , ~ - . ~ - • - -