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HomeMy WebLinkAbout0448 . , ` ~ ~ PR ~-Ol C C.~ U N T Y o~ C~~ R~.. ~J''~ '~'E ' ~ ~ . , ~ ~ F~TMENT ' l ~ , H EALfiH DEPA :~~ti~ ~3~i)1.2 r 1 _ 1~ ~ t _ • ~ ' ~ 514 EAST GRACE STREET ~ ~ ~ O - ` `EfiiGLEW000 ANN~ ~ AMQ ' ` "Y~E~ PUNTA GOROA, FLORIOA 33950 ' ~ ~ ! PHONE• 474-3249•', `~Q~E ~ ~h~t F~ . PHONE: 639-1181 ' R00[Il ' '~~S - ~ CLtRK Clt ~ ~ CCURT ~ _ 2 ~ lt~00R0 YER ` ~ ,?u~i 30 ~ ~a bx'1S 33~,i_l ~ CERTIFICATE OF DEATH Qrp~~lsr»~ o~ F~t~~l~ ~nd Relw6ilila~he ~tnices tTAT[ Fll[ NO a~cs+:?.~ c~ ~n_~~ rH F L O R I D A ~I~ , irlE Ot ~ftNl IN ~tl~~4~~~' RCOIiT1~A1~~! MO ?fR?~a~NT INK C Sff !W0100~ fOt OECE~SEO-?+.wE n~u •••oo.~ ~•u ~~t O~iE Of 0[wfN .•o.•r, o.., .e.~, '~~'Rp'~ , a:1E ' ~ '%,a~le , ::ay 16, 197E RAGE ~wn~ M~OW. ~hOK~M ~,.o~.«, wGE-u~~ w~w~ ~.e.~ w.w~ ~ w• DAiE OI RRTM ~..o..n., au. COU?+TY Of OEwnf ut ~ wtw~ ~ u~n.o.• reu~~ ~oti w.s ~ar~• r~+ ~u~ ~ • 'rlhite ~ ec. ,~~92 ~~:~lo~ ~e CRr, TOWH. Ot tOCA~ION Of OEATM wf,W c~~ ar•rf MOSMiAI O! 0~=~~ NSi1TUi1WJ-N ~u up~ ~w ~i*w~~, G~v1 ~rp~• ..ap ..w~~~ ~ 7 srean .~t o~ »o ~ Port Charlotte no S~ . Jose h__ H s~.~~1_ _ - SiATE Of i~RJM i u~+ot ~r ~r s~.~~+~ C~t1IEN di WHAi COIMrTR~ 4 MP~t1E0. NEVER MAlt1~0. SU~~IVlK'i SrOl/5E ~ w ~+~t. ~ne w.o~r .w+e ~ cow+nr ~ WIWwEO. dMOKEO ~ s?rcr. ~ ,t~..•~s~~• • ::e~~ Jerse . JSA ;~tarried Luc~Ann 0'Gor~ian oK.,uo - Y - - .~.eo ~ w•n. SOCtµ SECURITY NUM6ER ~ USUAI OCCU~AT~ON ~u.e au.n O~ ro~a oo-.! ou~~.w rof? O~ I[M1O Of WSWfSS Ot INOt15TRY o<cwvo ror~wc urt. l+~er. n un~ro ~ ,,,,,.~,~~p„ 1$ G F ?~.Lar en~er-Covoersmith ~t 3 9_~9_4 _ _ " ~ Phi? adelrhia '~avy _Yard__ s~~o« eES~DENCE-St~tE COU?+tr Ctir, TOwN. OR IOCwTiOr+ '~s~ ~~~n ~Si['Ef~ .w0 ?+UM1Et ~sncu~ ns o. ,.c,l ~yFloricia ~wCharlotte ~kPort ~harlo~~~ r~a ~~14$ f;•~ Gladis ave. fATMER-NAME ~~Vt r~oOl! uf~ ~MO~NFR-JMAX3ENNAME ~Nl~ . rWO~f t~f~ ~s Charles ic . Zane Lin~a ( Unknown ) IN/O~MwNf-NAME AtAIING ADGRESS ~s~ner p~ ~~e r.o, a*• w~o.», s~.n, tr~ ?'~:rs . Lucy Ann Zane ,~4$ :.t~7 Gladis 'Ave . PorL ~harlotte , FL. 33952 ?wRI pEwT?~ w~5 CwuSED ~r: ~Er+rER Orvtr Or~E C~uiE ?E~ ~wE ra1 ~o~. ~s~, u+p ~~p ~~~p~"~ ru NIO~~M OMM~ ~MO N~TM 1~ irwOi•a C•uff - _ ` ' te~ L'rer~ia ' IWt:. . . . «s~o~e..ce o `°"°"'O"'. C'onE es t i ve Fa i 1 ure 1 Wlc ~+•~t+ e•vt ~~ie ~o Ibl In.~D..r! i~uf~ ~0~. I OVr f0. O~ .s . GowuNVfrKt W ~I~~IMG iM~ VMOlf - \~IM(~ ~~V1f 1~1f ta" P.heur~atic and ~lrteriosclerotic ;ieart Gisease Yrs. ?At7 M OTHfR S1GN1fKANf ~pNpli~pNS~ ~p~*~o+a cpnt~~uu..G p q~rw wpt ~eurto t0 c~uu G~•e~ ?.~r ~~m AUTO?S~ If YES ~+~~e ~~MO~MG~ (OM- lill O~ ~OI LOl~~~ IN 'Jftt~~la1MG C1Vf[~ W O!~*w Ifi Tl~ Ih ~ Pn4ol7 I ACCIDENt. StlIC~OE O! ' OA E~-WJURr ~ rO.n.. p~T, r!•\ ~ MOIM MOYK1dE. O! 1JNOttERM1ME0 HOW INIURY OCCUfRfO ~ ewin~ ti~ruet or uuut~ ~w ?~~t ~ p~ ~~n u, mr ~ ~b1 M~ Nl M MI INJUR~ w( WORK ~U1CE Of tN1UR~ .t »u..~. srnei, r.~id•. IOCAT1pN e sneer w~.r o~o., c~n oe ro.... s~.~e ~ 11~lC~n ~!f O~ ~01 pIK~ ~IDG .l~C 1l~KIf11 ~ ~ ~ CEtiu~C~T~ON- +a..w n.r re.~ +o~.M o.. •.w usr y,.. .wi..n ~an~ o.. . ooiom «or rn. n.e o[~~M~Oteunen •r n.e n.ci, o.~ n.t ~NrSKe~N: n. ? • ~oo. .rn n•m ~.ov~~ o.n. ..w. ro re rV t~~ oece:sfo :~o: I0 27 b~) i~„ 5 16 --7 6--~'~~ ~ 1~ ~ ~u d ~ d ilOt 7: G r'j Piw ,o ~e u~ODU~i° i~:no tERl~K~.T~--MFOK~L EY~~~+ER Oit-CO40~+fR o» ~.s,s o. rw ..ovr o• oe~w. Me orceoe..~ +,s r.o..au..ceo oe.o ' ei•rn..r.0-, o~ n.f qo• •r.olo~ [ne ~r.v~irr.••Vr. ~n r. Wn.~O~.. rO..rw o.T .e.• ~.ov. Of~'+ O<CW~f~ O. Mf J~7 u.D D~ t0 ~M! C~uS!•t. S~~:ID tt~ M. 11~ CERiiflf4- N.IME ~n7rt o~ r~:..n f~ SIGNATURE~ - - -~---T--- - - M- r~ tJ . 1~, e L a ugh 1 i n, :.1 . ~ ~ ~a~ee o~ r:e ~ D~T SI O n~, o.•, .eu~ .1' ' .s~.~'A. ' ~ ~ _ "~'~~"`"°°.~SS_"Rr"~`-Harbor ~lvd .';~"'ro"r°t °Charlotte`; ~"orida 339`5'Z ~Utul, CREHtAi{prr. RFMpv~l CFMEiER~ OR CREMwiORY-NaMf lpCwTlpN c~n o~ ro.v y..r+ ~ sMC.n ~ 3vrial ~i.estlawn :~:e^~~. Gdns. Por~ ~harlorte, Florida ~ O~rE . _ - - - - ..o.~ o.. fUNf 4~tt HOMf - N~:NF ~?iD ~DD?f~S , sn n o~ ~ r o ~ o ~o~.., sr.re r~ ` ,.,:'av 19, 19~ ~.AYS ~';;::L_ ~L PA , f~Ggv:~2~~5~~,~'ort C~iarlotte , FL . 33952 S. ~F, II fui+Et aEft - G uo - - rEG~ wr - S~Gw~t RF D~TE ~fClrvEO ipc•i ~EGiin~~ r2ev.2970 ~y~ tis tp I hereby certify the above to be a true and correct copy of the Local Registrar's record on file in the Charlotte County Health Department at Punta Gorda, Florida. (Warning: Not valid unless raised seal of tY~e G'harlotte County Health Dep~z~i~t~ent is af f ixed. ) ~ ,t , _ i.;, • ' - ~~^':f~ ~ - • , • , --~.,~i~ r - - - - ' Coun Health Officer and Lo Registrar _ . ; ~ ,..'Z,,`._~: _ - _ - ~ ' _ - . . , ~ - r , (~r' ~ _ ~ ~/l Ii / - Date Deputy Local Hegistrar ~ r ! ~5~ F~G~ , . . ° ~t~ - ~ ~ ~.z~= ~ r b_X. 4' ~ . :