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HomeMy WebLinkAbout0772 3'74591 3`74591 ~ ~ ~ ~~~~~1~'~ L CLERR CIAC IT COUIIT s ~ «,:r yfR~F~~p~ > Auc 9 10 23 AN'17 ~ palm Beach County Health~ Department ! State o~ F?orida CERTIFICATE OF DEATH Deputment ot Health and Rehabilitative Servioes F L O R I D A ~TATE Fi~c No. _ ' V1TAI, 3TATIS7'ICS REdItTRA11•f NO OKtASEO-NAMf rreu ~~1t ~k DwtE d OEwM ~ rortr, e~•, rt~~ ~ TvPE ON PRINT ; JdR~s T. B~.dC~l~rn ~~dle ~~US~ 2~ 1977 PERMANENT a pE~~ ~ BIACK INK ~ACE ow~M. WiW. ~N~K~r ~wl~r, •GE -~.s~ W~Of~ ~ A~~ Y~q~ 1 M~ CA1E O~ ~iRM ~+O~+M, N~, ~ ~a ~ sncm ~ ~i~ , a~qpp ~•~•~s~ +os ~.,s wws w+ ~ ~ ~ ~ ~ , Dec. 24,1925 Palm Beach i~. ~OMM. O! IOCAiION d O~AiN ~fw tar ~w~3 NOSMAI O~ OTNE! NSTtTUT10fJ-W ~y u0~ w ~~M~, 4M fnl~~ u~ .ewW~ ~ ~i0 3 Q wca. .n a ~.o West Palm Beach Yes C,ood Sa~aritan Hospital ~ ~ «.ri CII~ZEN O~ vinu?T COWiRr MARRIEO. NEVE~ MAttl[O. SUh?NIHf' S~01JSE ~w aM r~~qr ~ure i STAft Of M~M . r wo~ r~t.~ ~ ~~~y~y~~ COM~w~ ~ ~ V~7l1 ~ iNCVt ~ „ VP.ra [1M._?{.~ ' utw~ MfNMp ~ ~'~'nI' • N _ wMM NdW~ s«Ull SE~'If11V NUWE~ ~ USUAI OCCINATIdi ~G~t sM M~O~a OPM MM~+O rof~ W RM~D O~ ~US1l~SS OR IlO11S~lY _ ~w1o. r M~M, ~rOUr'G ~v~. M.. r NMM ~ ' . ~N{h ~ a•. „ 234-34-2760 Aooo~uitant (brp~rat~e - - ~~YNK~ M~O~f w~YN C~ l~rM ST~EET ~!'1~ ~ESIOENCE-SurE touiatr Cm, tOww, w totwnon ~a'T~.~. T~w,~~ 1 W(Ht tH p MO ~ ~y F1~1GKi - 1• St. iM.le ~y V~ DGQ~iil 1~1 ~ IM9710 • • ! IA1MEt-NrwE r+a~ . rra~ uft MOtMER-~u1DEN NAM[ ~rs~ wea~ ~•f? ~ A. R. Blacklxlrn Florenc~ ' n IPMOWANt-waME w?INfS AOO~ESS ~~•Ma w~~•~.o . cm o~ w~... s,•w. t~~ ~ Vera Blaclcbu.rn ~ 9710 Hwy. AlA, Apt. 1208; Jensen Beach,Fl 33457 ~~u? otnm wws t~us[o ~r: ~t a+rr o~t c~ust ~+E ro~ h1 Al k ~.ew~o«w~ .w u.. M. w ~ 1~) . ~ COMNt~OMl. N ~~n. ' - . , ~M~CM 6~t~ ON q „ ~r~fN~t! t~Vft NI. ~ q. • ~K! p: . jt~~IMO t0~ YM~~F ~o~ t~vw. ust . ?ARi ¦ OtMN SICi~M1GwT COnD~t~OMS: ca.wua.a cawrrw.w w ww~ w~ .w+ run~ ro cwa c~nw .u~ ~ w~ AtRdS11 If tES .~a s~waros cor . ~ ns a ..o+ a M: : ~m~r...a ~ w ~ ~w Iq - ~IM0~1~M~M~tD ~•w*w. M~, ~u~~ NOW tNIU~~ OCCURRED i~MI~~ N~WN O~ IM/Ytt ~M ~N~ 1 M~~ft N~ we. ~ ~ ~ ~I M. IM ~'I 1N~NY AT wplt MwCE Of ~J1U~1i .r wow. s~n. r.cw~+. IOCAT~ON ~ snm w~.r.• .w.. cn. w w..~. s~.n ~ ' - ~MKlQ R! O~ ~+01 OAK~ MK..,~K. ~fNCM?~ i ~ ~ ~ CEpIF1CA~10N- .~w~¦. w• au ro..w~ o.. •~u ~w~s us~ s..r .a.ha~ .?.~w.on ~»/o~ ..o~ +r. +w~ oe~tM occuato .r re rucexw w~ 1 /M~3KIAN: lO Wt ttY ~OM ~~Rf q /wOV~r ~ O q M ~ ~ ~~IfMtO /wf I A • tMO~rI~OGf, 1~ :k ,N ~,s= 1N MG~1~~ /q~r/~ ~ 1N ~ ~ r cwfew fuw~ CEttIfK/?t~ON-M1~CAl Ex/?MV~Et OR C w nr ~.sn a we ~oM o. ee.r ~w~ oue~e.n .s w ~..~w.wo~. a w we. ..eio~ .w~ ...rsnc.+wn. w..o». •w+¦ ...a «ow N~w ocq~n w M w~t ~M w~ ro rt cwseM s~~we. M t?~ ~ - ~ tERtIF1E~-~1AME o~ (~••y ~ s SK,Nn aeca~ w~ ~ A E~ ~7 a~.~ ~ ~~I(~/ ~~I ~~-f-~r G ~ ~ ~ tf~ w MAll1G A~00lE3S=CFfT1/~ s~ ~~~o~ ~ ~n w~~ a ~ t» 7 ~4 ' winnt, te[wu?non. rErovwi frwEtEn ot Ut?~u?roitr-N~wE tOCwnp+ c~n w.o.A. s~..e ~sncs.~ H. Cr~ti~o~n ~Fbrt Pierve_Crematori~n - -----Fort P~.exoe,- - - F~erida ~ OATE ~rOMM, w., WNERw~ NOME-NANE INO AOONSS ~ srnn o~ e..o , c~n w~o.... sr•r~. r.?~ ~ ~t- 5 1 7 Inc P.O.Hoac 777 Fort Pieroe.Fl 33450 ~ V.S. xo~2 ~ . tEW11t~ 51CsNAf J DA f!<ErvtO ~t Ot~1 !lGISTf~~ / ~ ' y 6f L t11~1/ ~ ~ ? Rw.7/76 Zp : t~A.~ "~y .t~`Qt~~.~t,t ~ -'•?y~~f~~ ~ i . •~i~f-.~~~~ C'•.L . _ I HEREBY CERTIFY THE ABOVB~~ t~"+~MCORRBCT COPY OF THE REGISTRAR'S RECORD r;"X . i - - ~ ON FILE IN T~iIS OFFICE i-; •Q; S E"'~." (Not valid unless the s~~~tof=;~hC`~~l~ch County Health Department is affixed) , '-:~,`1 E . ~ ~~-;sa • : . ~ , ;s= ,r~~ ~=~~~:i~u ;~~0 ~ August 4, 1977 - `k'' ' ` ' ` ~ ~ - - - ~~'r.}~~ _ ~ C.L. Brumback, N.D. ' ' Local Registrar ~ Bureau ot Yital Statistics West ~aL Besch, Florida . ~ ~ ~ ~ ~ _ ~ 6001c ~ACE 771 ~ ~