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HomeMy WebLinkAbout1371 ~ , _ _ - _ _ _ _ _ _ __.~.__r. - _ . s_ 3~r~i.. . 3zo~so ~ F Q atit ~ce~~ Z~i~: c~K~~ +~t~. • R~1~?s. r J~~RI?~ - . ~l~R~ . i;.L+ij Ft?~tlRT ~ ~ Rstb~;~v~.;;F:~p LQ R O(,LfLtl~ ~eQ~~ ~ epa~t~nertt NN ~ ~I l'1 s~ PH'~5 ~ ~ ~ . ~ 32~U.310 _ ~ GI.ENN V. HOUGH. M. D. ' DIRECTOR ~ ~ CERT{FtCATE OF DEATH Qcprda~eal al ~I~aTtb a~.d R~bal~i~il~tinc $earlce~ SfATC FILi HO. - IN\'LW l.Y OF I IF.~LI H F L O R I D A ~ ~~~'R~~"~~ REGISTHAq•s NO. OFCfwSED-ruME ~~nr rww us~ SF1c DwiE OF OEwiM ~•oM~w, o.., ~n~ ~ ~ A l~cvt iad t/?lc~l ~ 2,~, l973 - RwCE vrwin. M~cw. ww~Kww u.ww, AGE-uu w.w~ ~ ru~ wot~ ~ o~~ DwTE Of NtM ~~o..~M. wr. C TT Of OfAiM OC. 1~?lj~~(~_ _ N~ANa~ T~11) p~_ ~q NpNf xK ~4~1 W tiG • A. ~ 22 I t. N' CIiY, iONR+. OR IOCATION pf DEAiN r+s~w cm urrn HpSMM O~ OTMEt tiS ii1R1pH-NAME ~r ?qr rr tnwea, ~ y~~~~ ~..we~ ~ s.ecvr .n p .a n-Se6/u/u~ f~ no N. f/' __~_eae~ta,l /'lob _~a~~_ _~c_L ' STATE Of ~IRM i r rot N ~,s.~.. M.~.e L1t1ZEN OF wMAT CONNTRr wtAtR~EO, NEVF! MAtRiED, ' SURVNNG ~ r vrr~, oM w~w.. wwt ~ ,~0~_(_Q~ cowwr~' //i S• A. N.qQ~EO~srtan~ t1~YQli~i AO~~~ - G/ /i SOCiAI SfGURlT1 NUM3E! USUAt OCN~AiION ~ Gn! c~N O~ vpc OpM! Oy~up rOSt p KMID pi NISMIESS p! TlY ~70 ~9 29'72 A „~`~cco "ru~,ai,~' ~x. ~ohe RES~OENCf -SIATE CpyNry CIiY, TOWN, OR IOCAT1pN u~+~ SiREEi ANO NUM1~El F.lo~,ida ,,,.N' ,,,Se6 ' tu. /YO ~ p~ uR~ BOK I 2 FAInER-NAME ntl~ r/oa~ uft MOiME!-MAIOENl+AME ~Wt roae uW ,s ~.c.u.cWlt . N O/EG~ .Si7u.uc ttNORMANi-fiAMF • M1AMING ADGRESS ~u4tr M~.~.~. ~+0.. Uh p W~+w. s*~+e. irJ ~r. wCL~Q 1~. ~Q/t ~n ~ ~~G 2 Se6 ~ F.~O/LLG~,Q Q • ?ARi 1. OEAM WAS GUSfO /Y~ ~fNffR ONtr OAE U!!Sf lF~ 1~ fQf /e~L Nl AI~q ~c ~~nOu.~n .~-:r ~ A ~~tru» o»sat ~.a a,~ IL rrie Yse i ,~.a~ l ~ i~,~ - ~ t 1!~ ~ ~ , , . .wor. . 5,,~,V ~ ~o~~,,,o.,,. ~ S I, ..M~cM wn nae ,o Is) ~...~o~.n c•u~~ ~o~, ow w, a ws ~ co«uow.rc~ a. ~ sr~~~~c trt vNSen i?~«o t~.~H us~ ~ Ic1 1'AtT OTNER SKrNIF1GWT CON0I~IONS~ CO~y1MOMi tOMWytNip p OU~M WI rqt ~t41tY W 4Wfl 6trlM w/Y~ ~ 101 AUtWSr li 1tES .~~~e r~..o~.:s ~ nt{ p MOI Aolqs ~w Mtl~rlrw: :u•t M OI~IM IM- i1? ts~cxey ~ ~rti~ENi. wr~~OE O! I1i Wl ~ roMiw, M~, ~eu ~ ?WIiR HOW INJVRr OCCUtREO ~ eu*[~ .urwe or uiwn ~w r•~~ ~ C~ r.~t 1h~MK.+~4 Ot 11~OEtE~Y1WE0 ~ ~ l0~. 1'Iic. M. Mi. ~r~1'.1RY wi wOrtlt MACf Of WJtM~ ~o..e, r.u, siua. rwoon, lOG?T10N ~ sn~a o~ ~.r.~. .a., cm o~ ~ow., u.w i /S~IGn 1~f W MOI p11(~ Mop.,l~C. 1lIKMII Ji~. ~M. 7~. C[Rt1iKAT~ON- .~w~w w~ nu ra+u~ wr . •ew~ N.o uu s~. wr/.e~ unf oM ~ aa/oa r.or vq.r ny oEwTn Occwuo •r nq wa. 7. y ~NTNCIAN: ~ TO A1 W~ rt/N ~O~t Y71~ Oi~~ IMOMI O~h. ~r~O. K~ ~ ~n(r~D1Y twt ~ /y 2 ~~r,~ p • a 7i~ wc~.s~o reou~ _1C I~? ~ 71a. ~ J 711. ~ V 1 fl~. !O: ~!I"~~ l'e u~osa i~s;:~: tERiutG?i~On-~FDKnt EX~MtnER OR COROnf~: a. r,a ?•s~s a nK waw p e~•w ~Nl OK~D~M ry ?pwpywCfO OW ~ s..rw.r,or. o~ nr ww woio~ r~r wvts~w.+~o.., w. .n a~+a.~, r~we~ wr nu ww ' oe.m occu~no a. ~.e wa ...e oue w ae c•~a? sr.n~. )h ML n1. tEat~li[R --wt,uE m t ~~n I S~GNATiRE ~ r!~- ' w c.{a-,o~ inu } A'lE S~Gr~EO ~-~ow~*. u% r~-~- 4~ /7 _ y m~ ~1~. S~ _ /c~LX7 tn. -~'C7 ~-1 v ~s~lj~ Q~~1 y~4~ ~~~uh,«.~ ~L~~v.i~~•~ D~ ~ ..,.o. S`G~.~, 338jo .,.a • • • lUD1Al, tREMAj~Ot~ REMOYAt Cf/~EtERY OR CAENU?iOR11-NAINE IOUT~ON an p q.n. ft~q ~ ~ sr[t~n ~ T ~ ~u Q j` ~ ~a nY<l'! 11~r~ ~r~n, t''- .S(~/t.f.ltns l~ DA1 ~ .~1 ?U!1[RM~bMf-~ur Nf~AOfiut S ~ tn1~~ ~~.r.~. uo., arr o~ towr, f~•u, [w ~ - :w ~tj~ J~~' ` n.. ~?afrit ~iirt~f~~ /~%~•2 .~r~fiiuarn` F,l.oiudrt iUNf~/1 E{T~Ri~~r i~ - ~ ~ iEG~SiRAQ--S1GNAfUiE~~~ OwtE ~tCt~vfO tOt?ii[G~S~~~t ` ~ . iSl . .1..•y lf>. C.~'. •I 7- / i 7~w.~~ ~i ~ ~ _ ~ . l . Zt I 7ti (L ~ ~Y ~ . ~ j 7~ ~1 'j ° ~ i~~ ~ : 'i'~~" is rue "•'o~py of the certif icate f iled with the Divis ion of Health ~ ~ in ~f~~kso~i3.t?e~~ Florida Ssa ~ ri,,R` i. VOID WI'.~'4t~fi`.SEAL BOOK~~~ PACf~~~7 ~ trar . ~ . ~ _ s.~~ .,z ~ k,,.~ ~ , - - s. _ -