HomeMy WebLinkAbout1145 . j
~
~ o:: s°:~ :ua~?u ~os v~TrFU. i~w
~t~. CERTIFICATE OF DEATH
F L O R I D A sTATt FIL[ •NO.
i.a.i
ord •Aen BIRTH NO. ~ REGI6TRAR•8 NO.
ro erl 2. YSYAI R[t1~ENC[(Raoel.or~.J1:.rI Jl.+w.ar+~- ~~t~rMl~~wi~~
P P 1 1. ?~CC OF O~ATN COD[ NO. a, STATE ~y ~M(~
and~~lll ~.OOIINTY ~OW~D ~ ~/1 ~1(.~?~~/dIj ~Ut~1lr~1~
e~ Pi.~.a e. ~s Rcs~a«cc
1 n per- A. CITr. TOwM. OR LOCATqN t. IS CE O~ OEATN c. CIT~. TOMft1.OR IOCATIQII ItK~DE dTY LIMITSt
Sunrise Golf Villa e ~"~0E~r uNIT51 ' ~
rii~. g rest'J No? VCJN/'(SC_ l~ijG.F D"i~/"~G'f: rc
t. IuYE OF (lI wN ta ~Mpitd. /i~e ~bed ~tbear) ST1lfET AODIICSS 1
6980 N. W. 24th Street ~/~I~ ~ t,~ e~l,
3. NAMt Oi A/i/Yt 1.~M 1. DATE XwN IJ~/ 3'~
~~~~o ~ - • ~ ~ ~ o°o`?n~ Juae 5, 1968
~~s• « s.t.e) ,+c fi ..:t _ ~
S. SEX i. CO:OR OR RACE NARNIEO.~MEKN MARRI[0 ~TE OF ~IIITX 9~ A6E (/l~ /tp/ ~ w~~T 2~
M~4 D~s~ Mwn X:w.
~
) ~ • ~Y ~1 7 ~ ~~J~J•'~ Cr
el r 1 t• ~ ~c•l/ ~ MIDOMf[O u OIVOIICED
p 1~ f a 1~ la. ywAl OCttt?ATIOn (Cia ti~/ e/sMt b+~[ IOS. KIMOOi WSiNE55OR INOUSTqr 11. ~IRT CE (SP~f! w/a?eys tWUth~ 1. CQ~ 0~ w~N//T O~~OIMi~ri
.1tA p~?- ri~~ ~/vorRia/h~r.esw1/~rtveQ / /~_/v`1D~ S~y '
•~n~nt Ui.-r ,1~~ L ~ i ~)1~Z? ~ f < / /
Dlack lek. F~TXER~ N4ME 1~• MOTNER'S MAIOEM IIAME
or f7 ~/V vn~G
~
iC~'/C . N/r'~
16. SOC1Al SECURITr N0. 17 INIORYA ! ttCMATYR~ .llbua ~f O ~
v
05 09 6 501 /i
1 r~c_D ~t~~NR y ~S G'/~'i S'E f= ~~C :fl ~ c~~/~
1~. CA{/f~ Of O[ATN (Ewf~? Mf/ ~+tt t~w~ pe? fiwt /~v p). (S). t~l (r).J (IfTERVAI ~E71Rf[N
F u n~ r~ 1 ON~ET A~D OEATN
e i e ce r _ r~sr ~ oun+ w~s c~usco w: EIeC~OCUt~OII
•unL !11• IMMED1ATf CAYSE
ce? e~r-
t i f 1 e a t t p~~W~y, q~, p~ To (6)
• ~ L A 1NI[~ /Kl Iu~ f0 .
1 O t R 1 t~~'
af~tia/ t4 rwltr-
reslstr~r . p,'ETO (t) _
tti,~~ nrx l~st_
• 1 t A 1 n T= O ?A11T OTNfII S~GaiKlltr OO~w~iqMS Ca~'1pRRwC i0 DuM ~V? MDi 11Mi[O 10 t11[ TElruul D~SEASE COMD~t~Ol1 GN[M M IutT 1(V . MAS AUTOPSIf
~ hour• at- F - ?ERfORMEOI
t~r d~~t4 S ~S~
~ o r D~ fo r• 1P~~? ~ tOA. otxR~~ Mow wuRr ocwRnco. (Ew1a sottire ia/rr~ i~ Pat ! r Put 11 y 4es i~.)
•~k1ns ~aj F~ ACCIDENT SYKIDE /qMKtOE _
~ d,.Po.t_ ~ ~j p p Electrocuted when boom of well driller came into contact with a
tion ef ti~E of H~r? M~u?, D~~. Yr~?
~ e, d, . , high power line.
~ s 9:~~ .-~June 5,1968
~ IQ/. M1URY OCCURREO IDt. M.ACE OF IN1U11~ (t. f~ ~s( ~osr. 20/. C17~. TOtNN. 011 LOUTIOl1 ~A~
~ w. Ndar rrd. «Alp.. n:.)
~ ~
p~K ~T O~;,,o KE ~ ~ resic~`enc~` Sunrise Golf Village Broward Florida
2:. s=;.. t d~c~~a~d /~w+ ~~fo •nd I~at aar n,~ ~Iw on 5 June 1968
~ D~~tA r~d ~t • m on t~~ d~t~ st~t~d ~bor~: ~nd to th~ b~it of m~ kno~l~d/~. lrom tA~ uua~s at~t~d.
~ ~ 1 1 1 tt~a ~ R •(IXlrtt N 14lt1 22A AODNESS 27t. OATE S~6KE0
ara to
~o.Q~.c. a ? ~h f~ _ Medical Examine Fort Lauderdale, Florida 5 June 1968
~ c e ue ~ t r~hqi+_ 23D TE 27r N~~1E Oi CErETERY OR Ex 23d.,10~AT10N (GVI. lwrw. t~utp ~St t?
~an cSyenJr~ j~~ /
~O ` ~ ~ 1~~,~ ' ~GGE'!`L!J/}/C Jc=~il,~iil.~S' LL~tt/~>> (..~t/A%~ " ~C ~1 .
t /l~3~
V. dl j~_ FUN N l WAECTOR•S~51G~Tt1RE, p[~qESSf,^J:+p/,%~! DA AECO.lrlOC4LRE6. 26• REGtSTRAN'SSiG11~R
~ ,:~`=~ti'f S~ ' •
Fe~.lY6S I ;f :/~i.I't i. f /'~1?~)'^?~~?~~-~ '.rM-l"~
~ . - - . F
CERTIFIID COPY ~
~ ~
~ ~
I hereby certify the above to be a true and correct copy of the Local
~ Registrar's record on file in the Broward County Health Department at
Fort La;fderdale~ ~Florida. T
~ .
~~~~•_-a~~ s ~
~ :,,~v \1j~f ~ ae
n r
~s (I~far'n~~~t'T~~t~d unless raised seal of the Broward County Health ^,s~rm
. : CA' ~''~~~~Lp~ j t is affixed. w r"°~°
~ • ~•r~~ r~~~`y ~ ' ~ ~'C)~l
l ~ ~.G T : -
~ ~.c:o
'Gi i ` ' w ~ ~,Tt
~ ' ~ I ` ti y ' J ~ ~ T C ~.r ~
..~~.6i . a;~ ` ==~R
:r, .
x~. . ~~i~ ~..i ' S~ p~"~~
~ ' • - - ` • ~ O p ~A
• • ? Cy~1C
~ . ~ ~~~`:.~'il~~s ..:~n~.i~ ~ 1 so
, a:~: ~ i. - c•. County Health Offi er and Local Registr ~
~ .~t--~~.~~' ~ ~ `~3- - .
= . J~ -._~~~y i~~~ ` - . ~
r ~ i4 `
~ ~ L
;5 ~ - .
Deputy Local g strar
^T,~ ` ~
- _ . . ~
~235 ~A~~4~ . _ - . - - - _
: _ _ . ~