HomeMy WebLinkAbout0193 3y7yui
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STATE OF FLORIDA ~ - ~
t.z~ 1.222 1U~~7
DEPARTMENT OF ~ ~e~. ov c~wn~~ '
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Health & Rehabilitative Senrices ~ ~
o'~c ~ ~ . ~ s~om cou,n, ~r, o~. ;
P. a e~x a~e s~, ~~~e f
state or Floriaa CERTiFICATE OF DEATH
Departmeat oi Heaftli ana Reh.bilitaci~e Ser~ices F L O A 1 D A ~wTC ?i~c Ho.
VITAL STATISTIC3
aca~sT~w~•s No.
TYPE OR PRINT ~CEASED-Nrw[ •~a~ r+«~ SEx OATE OF DEwiN ~~o..+., .e•~ ~
vERMANENT ' EDI'1A GRACE VERY ~ female ~October 17 1977
BLACK INK ~tE .nMS. wow. .,.~~K... ~w~~..., wGE-~.~~ wa~ ..w woa ~ w,r cwTE Of Wtrn i.w~w. w•. COUnT1r p OE~i?~
ta. ~ sncor ~ aan+~.. ~.euf r ros ~?.t ¦oun ~w ~ .
~ White 64 • Jan. 17, 1913 „ Sarasota
CIIII, iOWN. OR t i p OEAiM MYM t1111 ~~M MOSRfItI OR OT11ER NST qN- ~ r«a en+~~. anre ur~~ .w ..wn ~
•ntr~ .tf o~ Mo
Venice yes Venice Hos ital
~ STAT[ Of {IRM ~ r MO~ M ~ f., w.r~ CIlIZEN Of Mq1AT ~p~MlY MAlR~D, NEvER 1W~IED. StRVIVNG S1'OUSE /M ~rM~, 6M MMOfN ww ~
~ wcr~ ~
~ ~.w~ Nerv York • U.S.A. N arri~ John Edward Aver
'~'rl~f MC4tl~
~~.~o w w.?w SOCIAI SECWIiY NtYwER USUAI OCC1NAtqN ~ar~ a..~ a wou ewe wM.w .os~ w KM~D Oi NKllESS OR M~D1lSiRtl
OCCVMt~ N rO~IMG lN~. MM M MMp 1
:;4 ,r 526-20-2534 Contract Specialist U.S. Information Service ~
.o..~~sw... 11ES~OENCE-St~TE tOUM~r Crtr. tOw~l. Ot tOC/?1~OW M~w un .rws stlEEt wND I+uWEf
~ vec.~. ~a a .w
,w Florida ,N Sarasota ,M North Por-t •yes ,..218 Sco io
?w1MEl-?~AM[ na~ ..~oa~ ust MOiNE~-~u~OEN WUMt r+» ww.~ usr
„ Jim Watkins µ Grace Foster
INWRMI?M-IiAME . MAtl1Cs 400~ES5 ~sra~~o~ a.~.o..w. <m w.or», s~.n. t~~
Mr. John Edward Avery 228 Sco io North Pert Florida 33595
?~RT 1. OU?IN wwf CAUSEG ~r: • ~EwlEt O~N r ONE uuS[ ?ft ~r~E rOr Nl AL ~?+D kH Nn..~r o«u~ .r
y r.ra~ f~ ~
a~ C~~'Cf-j
COMNt1OM{, r? .
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~ lnr0 41rN up ~
t~ •
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~A/~,~V///1 ~nf w no~ tr~t~n ~ wuu....wo
~ ~C' [.C . fi A H~ 1w N~tw
~ O! {~OIi A ~ro«rN. wr. n~~~ MOW INJU~~ OCCUtRED 1~~R~ M?~11~ W ~MWf~ ~M !Yl 1 O~ ~V1 M~ nw
M 1M. ~ M. Md
INJ1Mr AT wORK ~tACE d MAJRII.~ wo.r. r..., s~. r.non. IOUDON 1 f~~R W t~.• MO.. UN M TO~, f~~R 1
~ wun ws a ao ~ a.Ke Mee.. ~c. ~ wcrn ~
111 7~
U~~1CwTICIIi- ..o.nw w• nu ra.w. e.. •eu .+o us~ s~.. w~.h~e~ u~w a. ~ ao~so w~ •r. w~e pt~n~ oetwatn na w.c~, a. w
~Mt3K4N" tO rd~M Mt RY W~~ q~M ~ OY~. ~M. p/q MH
1 wTRMf~ hM / p r~ ~~OMfOW. MI/
71a Nte~MO ~W~ ' 71~ ~I~ " f11 ~~~1 )b Oa M- t0 eq twft~t~ WtM.
CE~T1~1GilON-r[DICnI E R O! ORONER: w nu a•sn a ae ,bw a~.r we wceee.n ..s ee.o
~ l1AYIr1~L0~ O~ Mf ~DC~ ~~+0/W tM M~rfStlWip~. M+ ~n O~rwO~~. - rOMIM T~~
' N~1w OCC1M~lO ON M M~! ~MO NM b tiM C~Yl~1fl f~~AO.
M ~
GERIIHER-NAIME ~t~w O~ rrwn ~ r,~4 ~ pV wr, tlYl
~ Charles E. Koch, M. D. ~
E /
~IHG ADO~ESS-CEt1rf~E~ s~un w ~ e Mo c a sue s.r
209 Palermo ~lace Venice lorida 33595
WRU1. CRENI?TION. ~EMOv~t E~rETEfr OR ClEM/1TORY-N~E lOGT10N an a. p.,,. wn
~vK .
,y remation K~Fort Myers Crematory Fort ers Florida
OATE .nw~w, w~. nu~ iUHERAi MW~E-nwMf ANO ADOfESS ~ sn~n w~ r.• .w . cm o~ ~o.w. s~•n. ir?~
,yOcL 2Q, 1977 „~Farley Funeral Nome, P.A., 265 Nokomis Ave. Venice F1. 33595
V.S. ~12 f -LG~u tEWS - o~a~c enEO ocu ~ee~snw~
R.~. ~ne ~ n. , - x?lJC.~ . ~~1 ~ 9~'
. f ,
A CBRTLFIED (:OPY HOSfi.CARAY THE E1~OSSED SEAL OF T~ REGISTRAR OF VITAL STATISTZCS.
THI~ ~ A.,CERTIFIED CpP'Y= OF A DEATB BECORD ~1 FII.E IN THE OFFICE OF THE LOCAL
RECIST1tAft OP~,VITJ1~ $~ATISTICS, SARASO'TA, • -
' .S ' ~ . • e . . I , ('t , ..'Y ~ ~
DA?E~1`~,~;;~,~,,~ /~1 `7 7 '~L' 1.~~~ f G~u
DEPU REGIS
FILEO ANU RECOFi;~E C
ST LUCIE C~UHTY f«
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:~s~-r9o1 aao~284 ~ 193
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