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Home My WebLink About2265 ~ ~ y~/3 ~ ' ~~'~~s~ CERTIFICATE OF DEATH ~'TATt r~~~ No. F~JRIDA ~ 5,( ~ , BIRTH NO. REGISTRAR•• NO. _ _ 1. PLACE OF DEATH C Q No. Z. USUAL RESI~HNCE (w~.naK..r+nna trwisu~w:...w...•ar..~ oouNn - • Zio _ f~ sT~~ i' w couNTr , ` ....~~w.~. «-c~ - :.s-r-:~i~(-+~J s:1 ~-~u1 CI ~u ..u a.rk.~. tWu, ..~w ~va~ta STA t~ W. N.e.) ~ pR ~•MMN .w~w.~. ~u. ~Nb RUMW . ~ ~ ` . ~ f~2Q ; TOWH ~ I• ' - ~ • TOWII . . ` r. Fllll NAME OF l rt M MlW ~r lruutM~. s~w~ trMt Mtw~,t Yr~M~U STtEET !U t~w ~aratMl ~ HOS?ITAL Ol /fliJ ~ ~ ~ . ADDtEtf ` ~ INSTITUTION"= ' ti J v`f~ ...tth(~ t .l.Vsa.+,~..tr - - 6 ~ NAME OF ll1.sU (riiiil~) (Irt1 DATE u) tD•s)illearl y_ DECEASED ~~~,~`~`,~J. l C~ ~TM v ' ~ /"~5.. ~V' ~1 'b'' fTrw ~ Prt*e • . i. SEX COLO~ ~~l?Ci L MAl~IE EYE~ MAR~ ED. DATi ~I~TM A6E ~u ~w~ ~~~u u~.~u rn ~ ~ w~~ o~ro.~ , ~ .~..c~ ~ r D.,. ~ w.. ~ Iw. USUAI OOCU?AT10H~oh~ u.~ d~+A ~M- KINO ~ ~USINESf OR IN• 11. tltj~1 ItACE ~etw a tw~~ ewrr~l I2. CITIZEN OF WHAT ~ rwt d wu~ Mrw ~t n~~w1 OUSTlY r~ ^ / CO_U/~j~Y~ . ~ - • r,~~ ,f. ~ IL FATHE~'S NAMi woni~s wuo~ N/wF _ / - ' ~ li. WJ15 OECEASEO R IN U. S.AWED FORGE57 IL SOCIAL SECY~IiY 17. INiOtMANTt 116NATURii O y i7r. r~ R Nrw) (lf M th+ tY f rY~ d wr{t~l NO• _ t/V?F ADOtESi ~ _ , ~ W'-~ 1~. CJ?USE OF DFAiH MBDICAL GERTIF CATION ~wrcwvw~ sanvuN _ g~~ ~ q~ I. OISEASE OR CONDIflON ' oM~R AMO ourw yer YM tae (~1. l~l. DI~ECrir IEADING TO DEATN'(~ ~ ui l~1 ~ ANTEGEGENT G1USEf . , g ~1'~(~ l~ wt wtsw M~?bti erwliK~ 1J a~s. ~~iw DUE TO ( ~ tJb s~s~~ ~1 ~~I• ~is~ q W ~Mw e~rM (sl ~tst- . _ _ ` ~ ssek u ~e~art /~ih~?~. . ~ ~ aslArwi~. ~f~. ?t wn~u ~w/ IM ~~~rt/fw~ tiw Is~t. ` w Ji.n..~ iw;•~r..• ouE To ~ aw~lie+~tF~w r~i~~ OiME! S16HIFICAHi CONOIilONS ~ e~~Mi lest4. C~itiwi awtriMli~~ b fL~ loalA iat rt r~Aeli+1 t~ fhe diri.~ir er rewditi~w ~arww ieatA. I1~. OAT= On~ Hb. MAJOR HNDIN65 OF OIEIA'TION M AYiOKY1 f ~ ~ r~s ? wo l7 117.?.Ab) l~sYsl 716. ?U1CE OF INJURY ~e c., le w~ewt llp (CITY OR TOWN (GOUNTY) (STATEI i M II~. ACCIDO/T r+~. t.r~, aa.q. r. ..a. ~fMC. ~a.? If m4 ~uu wutuLl ~ w ~u~e~os ~.A+~t~ 1.~ ~ :ia iiue iy..e.~ ~o..~ ~T...~ i~~ 21~. INJURr 06GU~tEC :i . M cio ~uua ua i ~ ~ QMl - OF r~i~taT~ywo i~r~a¦ ~ a ~ INJU~Y ¦o~i L' ~r ~o~R I hcrtby ti/y (Jwt I all~ndtd (he detcascd Json~ 19~, lo~ l:?.~~. lkot ! laal snu• [Ae dc~~.r.*~d ~ ~ alitr. oe « t9 and that d~n(k occu nf • ~n.. /rnm lkc uei and on Ikt dn/c ~le(~d nbnr•~_ • ` ~ t~. SIGNATU~E . (De~ree or liUe) t7b. ADDtESS, ~ lk. DATESISNEO~ Q r.~i~- - , , ~ri. ~`J . ~ --J , ~~.L w c.~ ~--.r ~•~1.. ~ - / n_ ~ ~ 2w. ~ U R L, CIEMA- Nb. DATE iNc.~E OF CCy EiEIY O~ CtE?/ATO~Y 2sd. IjOCATION~Gt~~ Ww~. er e~~Vl „ IState) . ~ riOM~ a~ r~~ ~ rn u ~ - f / ~ - ~ F , ~ •L./ • ..t . . . ~ ~ ' ~ ~ i - ~-l - ~ / ~G~ ' e _ y e(iiu~~ O/~TE REC'D ~Y LOCAL lE~6,15~ tY SI6NATi{~E i2S. FYNHAI DItECTOI'S fIGNATURE ~~s - ~ . ` - b - ~ "`e' / LU . f iti.~ p ~ ~ << l~! . G; ~s ~U' ~,~4~~c. u. ~ • . . f~t.EO ~xo ~£cuauEO . ST.WC~L COl{N?Y fU- • . ~ ac:,: ~oti ~'vuat - 1 h~nb1? aAify tha ro b~ • trw ~nd aornct aoPY~l* ~IEP.x Ci ~CU , Rpbl?a~s ?~tord o~'+ fil~ in 1h~ Sf. luciN Gou~hl ~c~a., •,c , FIED .~r~: ~y'=:• , m~nt ~t FoA P~u. Flaida. ~ ~ G ' ' : , ~ _ ~ ~ t ' - ,~~s ~ s~. ~ 15 2 4~ PN ~ . ~ r ' i. ` . (Wetni NOf vNid ~ ~ _ ('~,py~ty Neahh Depe~tms~+t is sffis~d.) s_ , 2~,~~,.:.~_, ; , ~ r ~ - ~ c ~ ` 4 ~ 5 ~ . ~ N. MIIIER. M. D. ~1V~6~ ~ ~ ~y ' I R i~ttM - ~ ~~,.~~a-.~.. ~r,i.~ ~ ~ ~th Offiut i IACr ~9 } ' 1~ , c. ' , - ~'r, • . ~ y' y~a' ~.1/ /~~Q > ~ ~ ; , i~;~.i~~ . i~~. ~ . _ : pM~ D~pMy Loul R~ohtrK ; . ~ . . * ~ . ~j rj . . : , ~ - 1~ _ . . ~ . ao~x243 P~2265 , . ~ _ ; ' ~ • . . , _ ; . . . . - : ~ rc - ' - ~ _ - - _ w.