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HomeMy WebLinkAbout0240 ~u~os ~ Y ~ , , . d . ~ CERTIFICATE OF DEATH DepiNt~erl ~I IItaI1L aw~ ~i~a~~i~drlhe ~r~~iccs /TATE flLs RQ . ~r ~ F L O A I D A K7a?~~ wr~t n~Mb ~ } RE61fT1 S NO. OfCEASEO-NAM~ ~~H~ ~ ' r~OM! ~ ~~5~ o~it o~ otRrn ~ rO~~w, 0~~, ~~~f ~ , ~lanc!:e iieinz i•:etko ,!~'eTale Ccto~~•er 1? 1970 RACE ww~n. Miwo. uu~.;,~ 2~?Gf-~.s~ o..a~ ~.~u o..oe~ ~ o.. O~iE Oi ~tRiH ~.w..•Mti w•, ~COUHT~ Oi OEwTn ,,.~iN.~ ,.~...0.. ..0, ~..f wO~,.3r~w i ~ ~n~hi~e ~9 „ k ~ ~~arcti 17 ly~l Pinellas C1tr. TOWN. Ot IOCAl1ON CiF pE~iM ws~w em iw~n Hp~HiAl pR OTHH fiS1lTUilON-NAME ~r wr w un~:~, c.:~~ inar .~.o ..u.yer r ~ VKU~ rt1 O~ rhl ~ Dunedin Yes ti'.ease i?os~ital- S~AiE OE ~iRM : u wo~ u. . t•,~-~+t;UTIZEN Oi W/tl?T COUd~RY iMRtlED. NfwEt AtARA1ED. ~SUWiV'NC S~pUSf ~•~e, oi~e .u~Mn w~ ~ ta.«ti~ ~ - W~ppwEO. avo~o ~ vtcN, ~ , illinois tS .A. a Widc~,: _ ~IAt SECUR~T~f NUM~f! UStiwl OCCUTATION ~e+e ~~a o~ wu oa+e ow~..e +osr o, KWp pf WSIHESS OR INDUSTRY ' ~+O~u.A ~nt. tv n N ~tn~lO ~ . „ ~29-Q3-~.~:: I~ome ^~aker - i». a::r. hor.e RESJDfNCE-STRiE !CO~~NT~ ptV, TONN, OR tOCAT1pN ~ 1°'~ ~m u+n1 STREEi AND NUM~ER , I ~~vec~~i res w w- r~~- xlori~a ~,p :=ine2las ~Lr.edin i~.~ YP~ ~~~.2K3 °dl~ Lake 7i21a~e fAiMER-NAME ~~ni r.ppt ~ ~~1~ MOIHER-AtAlOfN NAA4f ruS~ ~u00tf uS~ ~s Lo~~s Fteicu ti~ar__~a Aa~s INfORMANi-NAMf MAIMKi A~dRFSS ~SnlEt O~ ~ ~.O Mo.i cF oa '~r.., sra*t. ta~ - Gprald ?'.e~~CO ~ u' + o (`~P :t. T% te L`l '2 : ~n5i2,~ .4r.~in..tor. Cij•..,_ . e_,.rsia^ _a., 70± ?ART I. ~?nOi~.~ ~ u _ pEw11~ w~5 C~uSfo tr (E?rJEt Ont r CNtF CaUSf IER tN1E FOR (ol. ~'b), wruD unvtEN oau~ .+r ee.,N ~..~to•.n c.usc • iQ~ ~ ~ ~ ' Y\~- ~f Q -?~~hI1'+LD.si! _ • • ~uc~e»:e o COMOtilOw3, •M '~I^-`{ L ~ ~ , srMI~M G~Yf I131 f0 ~ (EI ~ L„~ , 1 ~ ~ I~ ~ i-~ . , frrt0l~tt C~uit ~o+, i C..! 'O. G~ ~S ~ CCvltpvl~:[ O~ SIAIIN('i tNf VNDI~~ ~ l1tMG (~yf~ laSi ~ ' - . i~1 PART M OTMER SIGNIf~Cuai GW+~ttlprv5 =~+~+~~~s co~rn~~n.,w *o ot.n~ ~u+ ~o~ au~EO ro c.use ~~nti rJl ~ la~ Ai1TOIS11 . If YES W!~! /~NDIM6f COM. ~.ts o~ .•o~ f~Dl~lD IM OfTltrln11M6 ~/1yyE, SS1 t~l~ i', C 1 F" i ~ a oE.T« ~ ~'~tAL~Yati -r i~ V.'ui~[-v 1 L.~z Ca'_ LcG'[~ j3~~fa~fS , a{j0 iw I?rey~ty 1 ItCGDENt, IIlibDf O!' OAT WJUR7 , rO.~tw, e~~, ~N~+ HOUt ~ jMOW IN)URY OCCURRED • t~.+et wt~~t er ~Nwn ~w ~•et ~ O~ r~~~ a, nw 4 ~ ~ ~IqMlGOE: Ot IMIDE7EtYWED t . _ ~ ~Spa/y 900 ~1 !k M {tW ' INJtl~Y AT WORK KACE OF ~r~IU~Y.r .~..e. s~4er, r~0 IOCATIQN ~ s*~en e~ ~ r.o. ..o., e~n o~ ro.w, s~.n ~ ' -i ~ tnur+ ns o~ .+o: o..,ee ~.D3 , f'7 S~l; ; !M ' I tM H! CERTRfCAtIQN- .e~•~ e•. ~t~~ • ..a.+n. o~~ •tu ~~Ka use s.wa~~ ~e~ .~~vt a. ~ ao/~~w r~ew n.e OfwTn OCNRaEO ~i mE ?u[t. a+ M[ ~ . ~M~SKIAN: iO ~ +p+M D~• ~ttl ~00~ ~~rt~ Of~M 1~17tM0[D twt " j t 'ti0u~' O~it, ~rA, q AI! ~ES* !1. osce.uo iror JUIM1 i~ . I~~ ~!U ' 7u (,C ~ r' ~ G! j,~ `n< ~.l I~ / a !Ci tt~ l J n. . /7 w r. aw.uaoe. ow ~~5 M. ro nu uuseo~ snne CERTIfICAT10N-MEpK~i EYwi?~:r~ER fORUr~tR o~+ r..a ~.;+s o• r~rt w,w~ a• ee.s~ +~~e EOf~+t ~r~S iM~+WHClD Dl~D ~I~M~T,W~ Of. q~j;00~ ~wD'OI 'w! MnfS*Ki~~10w. : • Mw.O ~ +O~tM O~r ~ta~ MO~~ . O[~M pCCW~~'q~{ b~~~wo IItt.*O r~ C~yg S~. StrtC ' ~ ; 1t~ - ~ - ' ' IN ' J71 M: CERS1 j.. S SK,r~ E -~[o{re ^e • r_e `DATE SIGIVE~O p~TM. o?~.tieu~ ; ' i=- r ' in? , \ y. i ~yl ~ 10-.I,a-?0 C T~fq ~ • ~s~eee~ w~...o ..o u ~.w _ sr~n • - ~t~~t' h .'~?°~~:se ..linic Dcaedi~~ i Florica 2~~ ~ i~A M~r i ~ ERT OR ClEMAipRY-HM1E IOCwT1pN ur. o~ ro~~ a*.Te ' ~ ~ ~ . ~ w~~x ' tiv V ~P:(` s A ta , , ~ . . • y - ~1 Saints Catholic C m ' ' ~~y "~~~A • ._MONIE-NAME ANO AODfFSS ~ snen o~ ~.r.o ..o . ertr w rorw, st.rt. nr r 1 U ~ ~ j~=s Funeral N e Znc. 132C =ai?~ St. Lunedin r a. 33528 • O ' fEGIST - v.atU OwiE ~ECf~ ?OC~I t K1lwR - - L LQ~I`~G~ 2 f ~ . ~ - - ~ -i ~ ~e / _ " . _ s-., 9 o '.~it~.y- , ? _,~j~''~~`.~~ ~r±~~tf ~~r ~'w:fi~hat this is a true and correet copy of a certifieate ~ .~~~~g.. f~~4~ice of the Local Registrar of Vital Statistics of the ~~~?'~ealth Departraent, St. Pe ersburg, Florida. r:.__~~~~~~., _ . , - ~ 0~ ~'y~ ~ ,Deputy Local Registrar ~ _ . . _q.;.___ . ~~~~~~,~~~~1~~< _ CLERK CIRCU~t C9JRi ~~Os ~ - YE?IftEB Qcj 1 i 2 no PM'11 ~ ~ aao~~76 nu~ ~ ~