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HomeMy WebLinkAbout0138 ~ ~ rn~. ~TATt ~o~~~ o~ Nu~TM CERTIFICATE OF DEATH CO~~~ ~ ~U11~I?U OI YITAL fTATIfTiC~ ~TATt /ILC NO. • FLORIDA orA •A~w p~qTN NO REGISTRAq~B NO prep~rly ea~t t~~ ~~ACt 01 O~ TM COOE NO 2~ YtUAI A({IDIMC(lR~w~~~~~fl~~w/ Il...nrw.w~ R«.~ww~J I.~w~wl Y ~N~ • ST~TE C011MIY •n~ i~~~ ~~~I~il~ICl~ _ h~: ~Lo~:t OA ~UYI ~ c74GH e. v~~~ GT~. TOWM.dI IOC~TqN n rua a 4~?1M t. C1 TOMM,OII LOCATq R K 11(S~D(NCC ~~A~A~ INS~Of CiTr llwiTS1 ~^G~ 1NS~OI~y TT IIMITSI ~-y~. ~ O{.~ OC~~ rtsO ?u6~ vC(.t' C/i vcs[~9 ~C~ O. M1Y( ~ i~ ~N>ihl, /Mf N~ N N~~tw? t(MGTN Oi I. ST~(ET ~0011[SS pM A i~11M1 NOSMI~L 00 ST11Y IN IA y r r, IMSTITU1qN SD. F~I.A • + OSP Sw %U~ N'~~VI N/~ c• resp wC~ ~ NAM[ 0/ l'IrN A/i1~b LW DATI ~/Ml~ D~I YfY ~[C~AL[O ~ trrvt«r+.~~ ~E~I~AM•~I~ S~~ p a.THDtC~MpEti' .~f IS~ 3. Stx i COIOU O~ ~~U ~ ~ r~~~ND IKVCA MAl1~1C0 wTE Of ~1117N ! ~Gt U~ r•er• + wac~ ~ rw u~a ~ 1 e(' ?~,e .,u..? M..tl. D.w N.... Xi~. r r~ e• MAL(; ~V~F1 ~ w~oowcop a~~cco ~~~~1.~1C t)~7 b 1~ 10~. usU~l OCCU~~TqM (UMI t/~I ~'M~ ~~~t IOD K~N00~ iuS~M(SSO~ 1NOUSfR~ 11. ~~atMn•cc (Sr.r~ w~~y~ ~wwe.~) 1. uruc~ os ¦wr aawrnn • 1 tA ~~r- Ir y.rN t~ tK~ IJ rNut/1 ? l1~Yc~`cN/~n~~ F~-ui- Fc~~u2~e ~cc,..,~ S llelk ~11t ~ ~ATN(~ S N~M( I~. YOTNQ'S MAIO(M M~M( o~~+J Sr~auJ ~.,~J o ~ ~~ZA ~3E r~-F S1+Ak! 1 wAS OtCUSEO [VEA ~M U S. AlIMEO ~011C[S1 li SOCIA~ SFCV~ITY MO. 17- INIO~MAMT ~~ICNATYA~ / 11'~. r. ~Jrw~ If/ w~. M+w. ~.Iw~ ~l~.r1 N~~'~+, .t Albut OY '~1 /V tQll~ LG~ t / ~/T ~O a~r ?un~r~l 1~. CwYt~ KATM ~l~wte• ~~t~ ~~u n~u pnliwr/M {Al. s~1 (~1.~ . IwTtpv~L aRwE[N A 1 t0? ~A~T ~~ATN WAS C~UStD ~Yr n ~ OMSET AMO OCATN IMMEOIJIT[ C~YSE J.=rO G ~~e?MC~ ~W ~ •u~t tll• tA• e~r- . titfe~t• C~~fUi~~~.i/~~~. OUE TO I ~ Q/1~~Q~ ~C~~• ~Q. ~d~ _ •ltA t\• r~rd ~~e~ ~ t~ ~'~e 1 • C • ~ ~t C~YN~~~• • { r• fstrar +rv~~I t~s r~1~r• • ` s r~i¦~ ~~r~t !uf DUE TO (a) ~ 4 /1 I Q. ~ [ U'rQ. . ~ - r0 - ~ - ~ 1 t A 1• 11 ~ ~MT 11. OT~ S~CNI/ICYR COND~TIONS CONIfMMIfIN~ TO O4T1 MR hdf 11[U1F010 i~ iEIMMMI DISGf[ W~N q/l~f 1(~) . W~S ~UTp?SY AOU~• •f- ~ . , ? A~ ~M[0/ t~t d~~tA s YES MO er e~f~t• ~ ~ ~ ~ ¦~M11~t •11~ ~ ACCIO(MT SUKID( NpMIC10E a~~~ ~~u~Y oCtuRRCO. (Ewfa w~trrt Nf*/Yr~ 1~ Pvf J~r Pat !lyYew I~.) st~~e~t- ~ ? ? ? - tl~a ~f ~ T~r[ Os J/wr 11(~1~. D~/. Yt~r Nd~. ~ uUU11r a. ~w. 0 w - ~ = IO/. IMJUIIY OCCU~~EO blt. ~IACE Of INJUAY (1. M O~ ~MY! M~It. M/ GTY, TO*M.OA tOCAT1pM COYMTY ST~7E WM~L( AT ~ NOT-WMKE ~ f~~A.I~M/. Urtd. •~a aN., tft.1 N011K AT 1NOIIK t . hN Z~- I~ff~nd~d fh~ d~c~~~~d Irom ~ L . to ~`t-M •nd/~~t Nr A'~m •!iw on Ca:eM f D~~tA oecurr~d ~f ~•30 H ~n on fh~ d~t~ ~t~t~d ~Ow~: ~nd to th~ A~~t o/ in~ knorl~d/~. /?om fA~ e~u~~~ ~t~t~d. 11l lt~~• WC YRt i l 'f ! . r• pjt N fYG) ~ ~ODRESS ~ 22t. W?TE SKMEO ~a.y~.s. • lJ(i~~ \J ~ ~ ~Oi2~D~ ~7ATE tl r1A {7tcta~o~.i: ~ . Y' ~11M4. C~CM1TId~. ~D ~E NAME O~ CEME IIY OR CREM~ OAY 23/ LOtAT10N (GY/. f . M(WRfII (Shft) ~~~w ~~ni.~. z ~lL G.1 ~f b~ J c~2,i ' ~~C N' ~ECR/l ~ ~79GtF- FtA ~ j~ NEIIAL d[ Oil'3 TUIIE . . AG~/ ?S DATE R[CD. IOCA~ IIEO. R 61ST R"3 SK~MATURE A N ~ a••.~fes Ql~l,~,{,{~ t21Jl.~Lt D G ~ F"^ - ~ ~ _ - - - - ~ . - . . . . . . , . . w . . _ . - _ r ~ . ~ ~+~i?..•.~.~ • • S f '~~t ~ . . ~ T ~ ~ j .i'~:r. s , . . . ' f ` ~ ~ c~R~rr ~i ~:u corY - I hereby cettify the above to be a true ~~d correct copy of tl~e I,ocal Re~istrar's ~ s ~ record on file in tlie iiroward County fiealth Uepartment at Fort Lauderdale, Florida. ~ (Warning-Not velid unless raised seal of t' e Br~ •ard r~~ nt~7J`attl'~~t. is affixed.) ~ 12-28-78 C~~itity llealt~~ 0 ficer ~nd Local Registrar ~ ' ~l ~ ~.,Gd~'t-~ /V~ ~ ~ ~ Chief eputy I.ocal Regi trar y ~ ~ - n - - - ~ ~ ~ ~ 4 ~ ~ i? i _ ~ ? ~ r~~CORGED ~ ~ , ± : :;':TY. i-L~.' ~ , _ 4~ . . . , . . ~ 4~9'792 a . ~ '79 5 PM 2. i 8 ~ ~ ~ ~ 2 84.~!! ~V~ ~ . ~ - ~ ~ - - _ C~~i.F: .,:"r..::.:, :.i';rc~ ~ ` ~ - ~ ~ ~ ~x , y R ~ _ o ~ , ~ ~ _ . , -h_ _ _