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HomeMy WebLinkAbout0553 fILEO AN~ RECOROEO a~WL~3O ST. WCIE COUNTY fU ROGf R P0l1RAS ~:•t'k C~:tCU1T COURT ~p . Y~ ~~c~EJ~...~...ria~ ;3~38430 pEC 1 t 3~o PH'71 ~ , . ! . ._y*..._ _ ~..~7..~ ~-y . ~ . ~ ~t.. . . ~ .r. . t,~f~ ' • . e . . - . . . . . . ~ ~ ~ , ~ . . . . . ' . . ~ ~iri NEN 1ERSEY STAT~ 6EPARTMENT OF HEALYH ~ J ~ / r ! ~„c~~ nt~ ?+~r-dea ~'0 ~ CERTIFICA7E OF D~ATH STATE 1'RE HUMBER t1 _ _ _ - _ _ '_:s-=_ • ~ ~ 1. ~ 1'~E Ut !••u,tl i~!. ill.•, tL~+•7 2. Sea 3. UATk OF I,l:AIH~ ~ ' ,S :;f CE.S- ! 1; f,,, PASQU;`,~t ROGOLI~lO ~ALE JULY 9, 191~ - ~ r 1. .1 ,r . in ~1 s t lr. If u~'-~^?) His. 6. U.+[e of ij~cth T. Eys dcre~std c~-et io L'.~_ Atr:r,: _ts~ l~st ~ 1 l.~.~ . 1' e 1I~~r~ ~f~... fYes. ao. w r+..l~:~:nl~ (l~ ~ra. xr=. ur K,t: s ~j a.rr./ . ~~i ,:I ___j____77 ~ 2 /18~ es ~•t:~l~t ' l~ur,,} ; ! •.cr. cr (..•..~o ~ , ..~.t./l ~ ~ C:i:~z:n ~I +.`~at e~~.r.t~y) fU. !.lurial tieser Uarr~ed ~ !f. tiocea. 5reutety ::o. . .1 i~I~~~v v~J• xIC~OR'C~t_1 nIYUlCIdr~~~~~j4~j~.~~ " F'LA: f. t'c t1H 13. l'~t:.'1!_ RFSID!'\CF. (If irs:irotion: res~dence beEere a.i-ss5ion) C:..,r~; ~;.~i a. Si~ce b. Counry - ---~~I~`~--- FLORIDA F. Cap ~Y - - ~l tr: z to, : :.n'e n~~~el c. Cic~ , ~ (Checlc bn ?nd g~ce n.ir..el s' f•:~_~: C ` FORT FI ERCE T~- r~ ~t. F~,~. h T.~.. _ , . . _ , . _:l _ ~ r ,•ice .~rrr. a,~,.:ezsi d. ::ccrec dd.iress (!f ~u:al, Y.O. Adv:es.s) ~s - f?.~,.~ . f e• t 7 _ e? ; _ : . ~ sr_x e.:,~ . N~~: . c?our~ t ~ox l60 PAlAP4AR AV. : . a. ! _i . . : • i=::. nl .re :;r ::_~.rsq .-..,c~ :~t L ti::t~ it/r. ~ tca t/ ttl~~~d) l~i. b. }:ind of Hu+:nrss or L~d~u[y ' -~'_^.~:~~1"!~c~~liT!?i~ _ TRIA"lGLE CABLE ' 'S. r: '.c: . . IC. l~k,t~er's ~.ridcn Aac:e . ~ ~ ' +c~tvI j_ F.0~~~1t<0 GEFl~CCFA SCOt•if3CR t l'. .~r. t' _ a~.i A;..:ess ~i _ ^ _:`=.Tn11iQ i'i'''nLIt~~C 4i~ CLER~ISOP~T aVFe ~d0.'.TH (3RUt~~SWIGK FJ..3. 4' 14T r.\ : f! F;) ::y r~~!e. or.ly o•.r causr pr~ f:ne ~or (a). (FJ en-l (e) Atptoiir-~~•e i^.ocr.Q Gct>ecn i / ~..5« ~.:i d~3 j:'_c.:._~e Cr~•^!al__ ` ~ i _4_. Ct C~lla~ i,. " ~~ti e.~•.c/ ~-.,.s. F-' ~~.F.. - -7 - ' / ~ ~ c' :~I,_ _ :_b ~ u.~••; --f-- 1 ( I.cF.r''L ~ h~-._ c: ~~7 . ..r r: . ..._ar ~ . ' _:z. . _ _:r- ~ I _ , st . _ . } _ - - - - - - C:< <•; ..~t _..,'.1'r l .<<.` i,l. yr;_: 19a_ Cas au:opsy 19b_ 1! yes, ae:' fic_:r.,;s eons.'c:ed C: ;,y p:rfc:~~d? in d-tc:::i: ~.-:,_cc of dcui? Yc~'-? •:o;',•, Yes i _ ~ - 1~~ . ..r..!e ~.;.~:c ..:~1 kic'u ot L.j~~y tit. Hovr I~lia~ tT;:tsted tl:.y,r. r.1:wt G1 tn.a-~j a Fart i ~r I( e{ (:r~ 1~:. ~ ' i , - ~ • . ?r.:.ar_ !11. _ e. f's: ce 1.:ry %P.g m•i c~,.at l-.r.e. 2Lf. Ciey, le-.n or I.oczr'cn ( o:.r.cv S:aro .c a: - . ..•r ~ _ . J:~ . , sue~~t. ~,i'~c: h:i~.. rt:.l ~ ~ . . - ~ i ...~..,e.{.: :c~ 'ir. n, ro) '~f ' ~ ' to ~_j ~ii 3li~ I35[ S2Y {h~a, hrr) aIive on ~ ~ 1~-_ _ ---t-__~.- ai~..: e: ~_l to tfr h:~sr o/ ~:y~ knur.l~'d;;r. i.. ~ tas rau:rs st.::rd. . r l r i ; ~r ~ ; , r- • . ys. 215. Ad-:rcss i ~ „c [i_.' 3 ~ / ~ ~ _ ~ fG - Z~'..~~1:. . F`~, . ~ - • ~ ~ l . , jt`'' ` ~ # , ~ ./~I . ' . ~ .r •J'~.-~.'_ t- ' f ~J Of l.[tG:at^f :.171G . . l~ i ~ > 21e. Locauoa City e~r 5 - . . : t,: " ~ : ' _ ! =1's i~1. n < < , - - ,--i: - ~ , ~ ~ l'J ' _ f 1 ~ ~ . _ . . _ `:a. :r ` a }ro^e ~..~~r. _;b. Funrral }:o:~e A:.ltess ~ 7/1~/7Q~`Qt;,^.~~,i~,Ei~IIi~SS Fl1tvERAL NOt~t tJEI•! 6RUC1S~tICK t~.J„ y "1 ~ . ~s .y /)~-i` . i_'- ~~tl- (.t:~^'~~ ~ QfJ~ 5 fic~,ist:..r 1>~...~i~ F'cr.r~j -;i,;~.a~~.:tc :'b. [~atc i:r~_'.. ' ~ i ~f ' ~ I I % J ' - R r: : , i ~ ~-~~~-~-s-~/~%'l = I ~•7• ~T ~~~~G~-t-~-tL. C/r112~lL, .f ` ~ '-r-- . ~ . - s. ' r` HEALTI~ DEPARTIfE:t~' - 2+E~r isRU~iSi~iICY.. Il.J. :.2, ~~~,~:I~:.;::~;.,, Under e~y hand and 1I~alth Dspart~-::.i~ .~;s Q~`~'!7;ri~ ceal I~.ertjfy ti:~t this is a tr~:v. ' : , •~--%4 phutostatic ~epro3uction fro~ an ` . ~ ~ ~ ~~`r i~:.a~;o o? the original record., ~ : i .=:ti ~~:j • ~ ;y' : ~ ~7 F-= ' .i ~ ~ ! G{~L~? ~ ~ . , , I~ ! ~ • r ~ ~ ` _ ~~T • ~ !.~.F~7 -jr'.,T`;~~•.s~r~-~-LJti~ ~ , . t t~ ~'~I ` f :~-l~~t~t?~ ~ . ~ ~ ..rtl,~~~ SUL ~Ji: ~ .............Registrar c£•'3ita1 .,tatistics ~ ~ DO lJ0'!' ACCEPT THIS THA1tSCRIP'P r:~~ UI~L~~S THE IiAISE~ SEAL OF Ti{E - &E1,LTT DF.PA~2Ti3EtIT IS A~'~'IYED H~iftF70i~.. , . . : ' s°ooxz~~ ~acE ~z