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HomeMy WebLinkAbout0519 ~ ~ ~~i~~~~:~ f ~TAT[ so~wo o* Nu~TM CERTI~ICATE OF DEATH 6UR[AU OF VITAL sr~Tierias F L O R I D A **~n s~~~ No. _ BIRTH NO. RQ61sTRAN•S NO. 1?IACt O~ OtATN CODE NO. 2. UlYAI R[f10[NC[ (~?~w~ br«r.I h.d I! ~YhfMN~' RY~MM Mf~~ ~IAMIwI COUNT~ ~~s f~ ~ • STATE FlO~da COUMtYty,t,,,~~$ r,+.,m D. C1Tt, TOWN.011 IQCATqM K?lAtf Of O[~TN , e. CITY, TOMN. OR IOCATqN t. ~S RC5~0[NCF INSIDE ClTY UVITS~ INS'DE UTY ~IYIIS~ Ca.~earwater ~~S ~,,,o ? Ftecki.n„dton Shoros ! ~~S p_ ~o I. NAME Oi sN LNrQ~f. Iilt ~f?eN ~I?~t 1 ST7IEET AOD11[SS - MOSI1TAl 011 ~tO~~ P~~ HO$~t~ . INSTITUTIpN ? 771~ Gulf Blvd. I,ot 213 3 MAMt 0/--- }Ynt aftsue - i.,r • o..c l~~a~r~?• 3•.~:- °n~ N;°.~.n h~N AI~E.RTUS D?~~'FSt9F`R~t DEATM January 26 1969 S 5[% 6 C(HO~ OII MCf ~ YARNIFO ~?KVER MARRIEUC ~ DATE O~ ~IRTH ~ 9 ~Gf ptfl a V''~~ 1 i U~.p(.12~ WK . f~7y,~ ~^w~ I6lt AIr1W~~) Jdw~4 6~M Nw'~ .M~• 2~ZQ ir=~LtQ w~oowtoi~ wvoncto oy ? IOa USUAL OCCUMTqN (Ciet ti~I!/~[e?k lO~t OD KtNDO~ l51 f550R iMW5T117 11 6~R~NiiACE (Vdl o?/s/tt~~ toYnt~~) 12 CiTt2EN Of Nw?T ~'AUViAr~ trri~o sNf ~ wti~~ hp. rus 1~ rtnrdl rcr~n G~or~c & - ;~Iaster 1~'~achintst Qa]. Co. Pe lvania U.S.Ae I) FAlM[RS MAI~[ 1~ MpTNER~S MAtpEN N~ME ' ~ Ste~~art W. Diffenderfor h~therine (r'ot Knc~~n) j 1 16 SOCIA~ S(CUMITY NO (7 IN~9RMAN? (jf~7J]Q$ A!/rr~f S 212-~C9-8039 IficseHan~ Differnlerfer~ 17715 Gulf B1vd.Redir~ton Shores~Fl~r3.da IS CAUtt OF DiATN (Ba.~r ~~l~ ~tt t~rft ptr h~w J~r fa). I,1. o~I (tl.~ ' 1!/T[AVAI EE7W[[N ~ t11RT OI0.TM 7NAS GUSEO /r~ A~/~ - ry`_~ ~jf~ q ~'J~~ - OM$!T ANO DfATM ~~tVED11lTE UUSE S~`+`~~ •~V~!W~C!.C__. I~~A~_.~~T~ . . _ Co~1i[ba1.i/~e~. OuE TO lAl _.~'S/{.~_'}~ ~~~~!I{rN~~ _~+V _~~J ,~f~------- r~id yor n fo - ODOtt C~YH Jf~hn/ Ut r~lrr. p~E TO (t1------- : f/iN~ r¦au f~~1. ' O PART 11 OtMf~ 516NK1(AMl COMdiIOqS COMTM~UfING tp pE~TM !{!I IK~T REU/iD f0 iN[ TEIIYtIfµ p5[ASE COAqT~OM GMN lM ?Nf t(~) WAS AUTOPSY ; ' ~ fERiORl~EMO~ ~ s ~ES ? ~+O L? ~ p~ lPr ~0 ~ pfXRtsf NOW iM1URV OCCURREO lEnttr wNrrt ~Ju/rry P~?f ! w Pt?t 11 ~j1/tiu !l.) ACC~DE++T SU~C~DE MOYKIOE a ~ ~ D D ' -i 20t TIwE o~ !/oar M~wM, M/. Yto - - RUUNr w. u o P- w. ~ ~ 20~. tN1u11Y OtCU~REO ZOt ~L~C[ Of INlUI1Y (t. 1~1 M~OYf ~OAt, ~l/ C17Y, TOWN. OR LOCAi1pN COUNTY STATE ~ wNKE AT ~ NpT WH4E ~ N~w. Nrtery, it~ul, of/ict AfI~., Nr.) WORK AT WORK • Z~ I ~tt~nd~d tA~ dee~~s~d /iom A . to - •nd /ut a~r ti~ •/ir~ on ~ _ W~rA occurr~d ~t rSd~Li 1N _p!m on th~ d~t~ a~~t~d ~bw~; ~nd to M~ 6~st oI m~ Ano~I~dp. Irom fh~ uwes ~t~t~d. 72~ SIONAT/RE . .(/Mlri~ e? fGlt) :ZG AODRE55 22t. DATE SsGNEO • ~ . = . ~ '7-y~. D IN~~~N ~KJ . I-Z7 -G9 ~i 23a ~+Al. Ci1fYATpM. 3D W?TE . ~ 23: NsM[ OF CEMETERY OR CRft~ATORY 23d LOCATp~ (Cti~, (Nr~. N tO~nt/) I~~~~ ~ ~ rttrorµ (Jytc~J~1 i ~mqv_a an.2 1 6 = St.I,uke ~ s 2r.ethod~ st Cemat St..•iichael~ s '••:ary ' z! FU ~~Al 1YECTp11 5 5~GNA UgE AQDRESS ~2S DATE PFCD. !Y LOCAL REG I6. REGISTRAR'S SlGNATURE - ~ ,~~t ~tf1-~GJ_- $Emiuo!e Beacn Mlemoriai I v~ ~-j• ~ ' ~ ~t2 ' / (G , t~ ~ • ' : ~ - ~ [ h by cer~~fj? that this is a true and correct copy of a certificate E :'.,~ont~~,']:~i'in:~the Office of the Local Aegistrar of Vital Statistics of the ~ :r:Pine~~;sotinty Health Department, St~etersburg, Florida. ~ , ~ ~ ~,-`Jan. 27~:-,1969 ~,~=.~/y~r~ ~ ~ ~%~L~' •DePutY Local Registrar . ~ " • _ ~ ~ - ~ ~ _ " _ ~ _ t ~ ~ ~ - d ~ Y l = filEO '~EG`-~'~OEG ; gT. LUClE ~~~TRASL~ ~t~ ~ RO~~ ClfaK. Ci.~yV~T COUF 1~ - ~ ~ - ; ~ 2 44 PN' ~ ~ ~ ~ ry ~ 7 # ~ ' t ~ ~ 3 ~ : c;~z~ _ ~ f!; ~~0 11~13L • i a - 3, ~ i € - 3 f¢ # ~ i it ~ V ~ m~ - - "+~,?.?P ti~ y~ ~ r a a~~-xs~a>~: _ . . _ . , r