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HILI.SBOROUGH COUNTY HEALTH DEPARTi?~ENT33~3O3 '
1420 Tampa Street
John S. Neill, M.D.,H.P.H. P.O. Box 1731 Plant City
Director Tampa, Florida 33601 County Office Bldg.
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tiillsho~cu„h 39-062 Florida ~iillsborou?h
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INSTITVT1011 D. G, r~. ; 3~-~s General 1710 Council Drive - .
3 Mw~t[ Ot Fir~t /llidfe LaM 1. DATE AlwtA D~~ Y~u
o~cu?sco oiwTM Rpril 6 1~366
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~ S. SfX 6 COIOit OR MCE 7- MARIIIEO ? MEYEA MARIIIEO a'T[ Of N~17N 1- A6f (IR (t~~ K w'xa t tU~ ~~s {p~p(A t~ MK- ,
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~g L'1ND t~OIDe • • • •
1~. FATXER'S MAME 1~. MOTNEII'S MAIpE11 NAME ~
Jo~n ~.j°:.sen ~;arie Neilson
, 16. SOCU1l SECUNITY h0. ~ 17 IM/OIIMAMT • NONATY~t A~~p ~
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WORK AT WORK ~ ~
2i. !~tt~nd~d th~ d~u~~~d /rom . to •nd fuf a~~ h,m •li~~ on
D~~rA occurr~d ~t ~Q P m on th~ d~t~ st~t~d ~bo+~; ~nd to th~ b~if oI mJ kno+Nd1~• born th~ e~uw~ at~t~d.
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23~. WmiLL. U.tr~rrY., ~ 236. D~TE 2k_ MAME OF CEYETE1111 011 C11[MATOQr 23/. LOCATION (GY/. IMVA. M psllf~l ~Sfdt)
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nh~ +l~r~I 1 b Sar~sota Crer.?eto Sar~sota lorida
i WRECTO~ / Tyg ADOBESS 2S. DATE RECO. ~Y LOCAL NEG- 26 EGKTMR'S 516NATURE
.L~,(~'~ -~J Ruskin,Fl . ~pr. 11,1966 ~
I hereby certify the above to be a true and correct copy of the Local
Registrar's record.,on file in the Hillsborough County Health Department at =
Tampa, Florida (WA121~ING: Not valid unless raised seal of the Hillsborough
County Health Department is affixed.)
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l.~ ~ k~ County ealth Officer and Local Registflar
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