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" CERTIFICATE OF DEATH 4i~6O~:) ~
1TTAT[ EcItE NO.
lkpw?Itttcwl d I L.hh wnd Rdtaldlitatttre $etYtceR
. Iw`tyt,~ ter 1~ tETlt ,FLORIDA REti16TRAR•8 wo. `
n.s.Y • •ttu nawtr•
1 i?E, Ot /RINT IN _ lass SE+ OAiE OE DEATIE 1 "ONtN, D..,
?tRMANlNT INK pT{EAS[D-NAMt cost tstso?t
uE KlumsooE loe RAY FT~e,~; T C ~
E:slelrawRS i- ,
artlKaN wouN, AGE-raft uNws't n.t YNOU t Oa. DALE OE RIRTN t..oNtN. at. COtNa1Y OE CEATN
to aYrt, Ntfilo, wrwoa. t rtassr rOS. o.n NOVSS nas t
etc. t tatty. t . 1~. 14,1903 • Broward
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C1tY, TOWN. OR LOCATION Oi pfA1N wNM ern ltr.n NOSMTAL OR O1t1ER WSIItU110N-NAME .N Not w t,tNts, ens star at0 «wuu .
/ srtcyr ns oe Ito 1
h allandal ?t. es 1825
~cluth C?cean Drive
- --Tua`vniaG STOtJSE tr i.ut, otit ratot» NaW l
STATE 0? RIRM IN Noi w Y.s.a.. wart CIIIIEN Od WNAT COUNTRY W~IDO~WEO, DIVORCED tveerTt
t°t"""' u. -IR7IR~G GOLI~~SAN
vtwt asa?fNtt RJ.LLIZIWSSV.u_ s V.?~' •n• IR a•LYPi~1A+u
rNet[ utetaxD SECUtitr I:Ui~1ER uSUwt OCCUMTION Iwti erle or .+oee Dore oY.wa cost p KIND OE iUSM.ESS OR ENDUSm
u•to. Y wan vWar+6 INt, nt« N unseo t
occwa..t X36-05-9243 . E>,. o~•rx xol~
IN,layttDN. (rr.t ~ I,.. HOUSEWIFE
:evotNte soon _ wstot car terns SiREEt AND ItUM~E[
anwsuo«. RESIDENCE-STATE COUNTY aTr, IOwN, OR IOCwT10N ts?eeai its oa Ito
Tt~ YF.S ,t,1$2 So. Ocean wive
tt. F~,oRZna to BRO;~AxD Ttt
tafr MOWER-AtA1DEN NAME teat rrDtat tas!
iAInER-NAME ttyr tt100ts
Paul Bridge N. IInobt.
u'
tNFORMANI-NAME MAR.M/G ADDRESS lour oa s.r.D. NO.. cm M rorrN, oat[, ws
IrviY
, Gold~>~n t», 1825 So. Ocean Drive9 Hallandale Florida
PART L DEAi!1 WAS CAUSED RY: (fMER ONtY ONE UUSE ?fR EWE FOR (oJ, tbE. ANO icJl setter o«stt at
~ ..n
awV
1 It.
elute Coronar Insufficienc
v a CONNOVt t t.
v CONDITIONS, II aM,
. n rwttN ...t .rte to ~1 Arteriosclerotic Heart Disease
urrtwatl cause al, pr! re, oD as . coNxOY[Nte p:
SlattNG iN! VNOtt- -
~r~ If LNG CaYt[ t?il
l J 1~1
AVEOtSY If YES ~rttt r.ND.Ncs c
BART 01I[R SIGNpKANT CONOrt10N5: coNano«s co.nntvtt.w to otAm .YS Nos .[uaD to uvss cnsN w .asr /lot Irts oa Not oOtOe: M Drt.+INwa u
- b- T 1M
/ lMtl NalYtt Of IMWti W Ia.t t Os Ina Y, Rtr /R!
b~E~rT ACCIDENT, 34ltttpE OR DATE W1U?iY [ra.rY, oai• seas / t10UR MOW INJURY OCCURRED
f lgMK16F; OR W~~DEIEtMnaED
9i00t~DD •1-_~ 7M 70t. M. 1N
INJURY AT WORK nwCf OE R2111RY ar «ore, Lau, Starr, rattOSi, IOCAiION t stt[r Os s.t.e. NO., ten O. sorrN, rate t
I lrtctrr its Ot N01 ON KS stoG.,lK. t1?tCNrt
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CERiITKAi1pN- N¢iiN tlai rtes ttOttot oar iW ~tNyM MNTwls Il uON ~OOr un a.m ~ OE~tOCN an
~•~n ti ~•t
RNYSKUN: TO p Ni r+G~.!X.[
I an[NDtD iNt tt? l1t. Ti/. Ttt. M. so •re ea+x a s!•
Iir OlgaxO npr 1N[ D[Ct0[Nl rat rrONOUNC[O ptaD
CERitfICAT10N-MEDKAI E1<AMWER OR CORONER. oN rNt uses p tN[ NOV• p paw NONTN oai .tan ttOYr
t[arlNa7~OM p M root aND/Ot tN! wrt )r ~atpN• ,N re pIMW«, 9.4U 7
- D[aM OCCVtttD ON tM Dait •«O pK p tNt UYSI tSt ftattD. ~ M. TiL
)b SIGNAiURE' orate oa talc OATt SIv*:f0 t~••^ ~••.,u
CERiu1ER-NAME mn o. tt~Nn a lea (~y~ f r
~MGeoffrey T. Mann, iVI. L~. Fx m iner+~+ U ~ `l - ~ ber 2 1
,raft OS t t.D, n0. CI!i d town Start ^ 2
MAtWG ADDRESS-CERJ:f1ER ~ 1 ~ ti
l71. ~
~ tURIAt. CREMA110N, REMOVAL CEMEtEkt OR CREMATORY-NAME tOCATtON - ur[ M rowN stare
l~'l ts.ttN.t N.W. 137th Street I~aIIZi Fla.
; l..Ii Burial N:ount Sinai Tt/
~ - DATE u.o«nt, ai, Teat fUNERAI HOME-NAME AND ADDRESS . unu of l.r.o. No., car o. torN, srau, st?I
,y Oetob2r 3, 1973 tstRi ^ha~1,16!!gJ ?1 E 1 Ave. *!o. I~3a.^'d BeaE±h F'? p .
verside I$nin.,. • q
REGIST R-SIGNATURE / I i OA[E sE~rtO tl IOCLI tEO.Sltat
~ Y. S. fEl? ?IR .111 DIiECTOR7SIGNATURE /1
- Etev.l97D TSL -GC: !/GL~i``Q t.. ~ ' J- ~ •<<; .rc/~ to ~ ~
- CERTTFIEU COFI' - -
~ I hereby certify ttlc above to be a true and correct copy of the Local
Registrar's record on file in the Lroward County l~ealth ilepartc!ent at
. • Fort Lauderdale, Florida. - F;~~p ii~CORGEO
. - 'T. -
.~~Narrifnf:' Not valid unless rai,,ed seal of the Broward County Health -9
DepartACnt is affixed.) - 4 -
~ ~ ~IU ~CC ZU W~- J
- - ' ~ C iJc y H~<<lth~-Uff:<:cr and Loca'~"~tcCi;;trar
} ,,;f .Deputy i.:ocal IteGi.st; •ar G .
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