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HomeMy WebLinkAbout0913 ~ Microfilming Memo ~ The quality of this copy is unsatisfactory ` for Microfilming. . ~ ~ ,5-~I ofj~ PO LK C O U NTY H EALTW D EPARTM ENT ~ WIIUAw i. Mlll. JR.. M.p. r ~ O~AtCfOQ ~ ' SS CERTIFICATE OF DEATH b Ilr~.a~liwrnl ..i i i.•.,i~~. :,~a t~~t,.~i,t.,~~.~ ~.~~~n F L O R I D A STATE r~~~ No.___ _ i~»ia~~v~ir ~s?.~~i~~ _ M V.~4 ~f~~i R~ ft~}F • REGI6TRAp•S NO. ' ~ ~ ~ ~ I~ ~ . .:~ScD ~-rV•vf ~ ~ •-a~e stt Uw7E Os UEaiN ~••-wr.. a.r, ~ . ~ .:i•'.~ 3;,;,i:o:i r-~rnett ::~3?~ ~~~2;;`: ~3~ ;~?~3 ' . _ i~C: ...~tt. ..h:~.~. ~..e~,c~r. ~..o•..., wGE-~.s. -••o•~ ~ ~_~~~~_~u•.nH ~ e.. ^ Oa?E Of 6~PM o... l~~Ol1NiY Of-p~ATN ~ X . ~.~c.... ~~.~»o.~,~~e.~~~ ..c,a w.s »:w.f .w j .e.~~ ~ 1~~ . ~ ..'i= : ~ I~. 1,, I 1. :,v. 11 ? .,7 1,. Y<+? k ~ ~ U:~, TOwN O~ lC~i+~t~UN Clf O.T~Ie~ -----~T ~~.~a~ un ~,.ai I~OS?li~l OR OThER,WS/11Ui10N-ris•~f ~a ..p~ t~~»r•, ~..t vr.u ..ur~e~ : ~ tt 1~IC•1~ ~ft O~ NO r~ i~ t ; i ~ = In :it±a=.t of ~'lori_~a i?OS?1#%+lA~ .i(~• . \ - - ' • ~ _ J _ ~ . ~'.aii C: e~ir?~ . o~. ~~~Uf12EN Of W~ewi CCl'VTR~ ~t~AiiED. NEVER lNwRbEQ ~SU{3~vwG S~15E f•i ~~v. c~+e uf~ .....e ~ . ~ ~cti,.:..~ wipOwEO Dn~O D~ cv+~ # K{E ~ • ~ ~ . ' q ~~;11'': ~ 1:.3l1 _.L4 --1'~~"~ri~_ 11 ~--V?~_~.?rLRC .l7-i'~-- -~.','~n - - 1 _ 1:.'+l SECtl~~ry ~+~JMiE4 USUAL OCCUtAliO1V ~ u.e ~~~c o• .ro~~ co..e wn~+c .osr o? Ku~p p~ luSu+ESS OR ~r~UUST~r ..o..~*.c u~e i~e.. ..en~eo ~ i _ S ^ry ~ . u _ ~:_t _ <<o7-A n. ShePt ~ ~~l ~A'!'~'p~ ( ?et. ~ ~n Co tri:cti_~~n ~ +E~4~.Er+CE-S~~" fOU^rir CITr, IOwN. OR LOC~710N u.sro~ c~~ t~..•r~ SltEET wND ?~V+~sER { ~ srlC~~. sts o~ ..O ~ 'ZO~~'~=i i~~ :Ol?t 7'IT'.~CP ~u ti~•~3 ue il.~ti. ,1~:a v~"?3~ ~ U ~a-•.:a ..r~,~.: ~ n~s~ wcar us~ MOtMER-AUIDf?~N~wi a~u ..a~~ i':' ~ ~ !f ~ 'i~2`~f.'tL „ I.A:.t~R i.tj i•7i ~ ~ - _ j t~~y~7M.W1-NaMF MAtl4VG ADGAESS ~suen o~ ~ r o ~o. ore a. s..~e. t~•~ - ,u~ • ~t: t:T3. :.?ttl.°.T'~R? ti• r3i:l°v.~. p.~)C 116~ ~11T1!~Q~?~ •i'1p,..i-11 3-• ~•~A i r +aii 1 ps~~ WAS CAUSfO !Y ~En!E~ O:vIY Wvf UUSE ?ER U`~f iCR ~b). wr.p ur~.. ..~.~t u.•t~..i ~tr~=r~ .;.tet •~o .r••.. - ~ ~ I~ _ ____wW?.~•1 (~J)~ - ; t:zt.ur~l :3'1;;°S ST. LUCIE COt;NTI? FLA. ~ ~ ~ ROCEF PO+T~~S ~ ~S ~ COMtk7~Fw!t :l• ~ 4 F~ '.+:IE: , J co~o~no..s. .r... f PTr~f;?}i?? ACL'tP 'r'-Yoc3riizl Ir.fara~(:~OYI ~G ~ , c..t •.st w Ibi ~ ~.i~,..e c.use ~o~, ~ o- e io. e~ .s . co+i~we~.i.e c:.~ ~2V~Jl~IJ r V Y~/ n~' - - ~ :•~~~tii Yw)!~~ ~ i C~Vf! 1~5~ ~ ~ ~ ~ 4 ~;'1 ' ~ s ~o»- ` u aa~: u Q/HER S~hii~aNi ~~tiGIT1ONS ~GrDJ~pwt Cb+'~'\U1~V( (O Dl~M ~J~ w0~ IfU1itD t0 L~US! 4~~fti • cm AUipK` IF 11E5 n~m.+c ~ - _ - ` nes OS o. s•or.ea ~r ene~.~.~we t te ~~~ro c :-ul-?~. ^r~ :in~^,r:,e~:~ . ~a :~O ~ ~ i~•oC•.J•1 •:UJ:uT. "'tC17E OR DATE OF 3NIURT C~+rw. p~t. r[~~i NpUR HOW INIU\V O:CUQ~~D ~1~4~ ~.~'v~e J~ u+~~~r ~v ~~a! n~• n urr ~ rJ~r.:'9e. O! C~:OE~E~k~NFO . 1~.ea~lr) ~ ~w' Yd! 70~ M~ 201 4 Y. , i ~ - iu:utr ~T wC7e riACE G~ rvr~~r.~ ~o..e. i.nn, r.u~~., tGfwt~Cta ~ snen o~ ~ r~-.o . an o~ ~or~., su~e ~ ~ ~ s.e:~•, .es o~ ~ •o~ ~ce a.~•, , nc ~ veon ~ ~ ~ ~ CE7~lf:CAT'~N- +C-.~w O•r rt~~ ~J~rn D~. a+.9 ~~1~ L~ ~.r/wE~ ~~.t ;v ~ D!7/ON •.Or .~.r t»!'OEnTN G~CU~iED t«! ~u..l. ' ~N~y:~~~N. i ,vTn L~• •!~1 ~0~~ ~•ff~ Ct~•h w~~~1~ L~~l. ~'-O, fr :M ~Ri• ~ - .r~rD~O e-~ f0 0... a..o..~to~e e:.e . s :t~t.s:o no~ ~1!~ _ )fc Y )t~ ~:4 r~ ~a ne c.ose a~ , . ~ ~~it:•iUTtCN-MkD'CAl EIA-MLVER Oi CO~O1rEf o~ ~~e u~~s u r~e .wu. o~ oe.~.. ~»e oeceoe~~ .+.s ~Sw»v~..cm oe.o l~~~ r.r~0« O~ t..~ f09~ ~tiO/J~ w.~tr,r~~•~0.., « rr O~~rni-i, rCwM D~• .7 t~• wJ~I 1 . o•.,• :cc~~.:~ e-. n.e o.re .»o o.e u•.sr u ti•.~eo ~.~!1 M 71~ 3 '3 ! 3 1: U7 r~ M'• 1:v ~ i C[~DFl'.~-!:4vF c.-~~ n----- - SeG?~ ~ cr.•~e o~ nnr~ D+~tf SIC,r+EO ~~c•..»,-o... ie.~~ e : . i:~arnton Jr. i:3 ~ ~ { ' ~t, ri_y -~rk r.~n~NG ~OOtE55-CE~nfrt~ r.ee• o~ . r o..n orr o. ~u+. T. yt.~e ~ ~ '1~ :r7;1~:: ~~_!1 ..ri~ t~~l,r,n`- ~Ll` i~7~{,t1 33'}~ ~ 3 J*~al. CQEMAi:GN. Ap.wpVAl CFM'fER'I O* C~EMATO7Y-NaMF ' IOCAiION un o~ f••:~ ~ys.e~ ~ _ . ~ - 3uri~1 ru ~'or~st :jt71 C~.,e:er~l ~a •`='i:-~s City ; Da;~ ~..e~~» o•., fUNEiAI MOV°_-N~ME ~t~:: ~AG?ESS ~ surn o~ ~ r o ~o. ur• o~ +o+r, fr.rr. t~?i ' r t ~ ~ .:~s ~:1t"C'1 ~7 ~ i~,~r~3 )S~ I:!I:?-~~pi ~ :l~n;.~-~ i ;•'r C;}:, ~ ~ ^~a.f ~`l n.-t t ~ ~':.~L a` N~ti~E~ l ~Q)[~T «TSi('iNATU. R~IS . -S1GN~iU~I , ; JI~ G~tE tiC(ir:0 ~U~l tt3tSi~~t ~ 7,~ ~/t~ ~ :1?_ • . ~ i~ 1 • ~ ~~'1 / IJ : ~ ~ 71~ ~ " ; ~ - ~ . ] ~ l ( ~ : hereby certify the above to be a true and correct copy of the Local Registrar's record on ~ : il~~ in the office of the DIVISION OF VITAL STATISTICS, at the POLK COIIItTY HEALT~i DEPARTMENT ~ . _ ~ j,f~~'I'ER HAVII1, F'LORIDA. f , ~ `i f j ~ ~ ~ /`l~~it.?... ~ f'!~.`v~ ; U- l~- - ~ / i I 3 1315 County Healt~Off~c,e,r ' Registrax , , s ~ r y~ ~.S i: ~ n~ ; ~ ~i _ _.te Issued ~ ; i ~ , ~ / j put~r Registrar ~ . i.'~, : ~ ~A ~ ,r~!~~r~ ~p ~q ' ; L ;~<<-' E : :t ~4~ PAff s71i ~ ~ t .1 ~ ',:'~R~IIi:G: Not valid unless raised seal of t~ ~~SION OF VITAL STATISTICS, POLK COIINTY HEALTH DL'PARTt~NT is affixed. _ ~ ` 2 ~ ~ - < r . _ . ~ ; ~w ~