HomeMy WebLinkAbout2755 ~v ~
~:.,a t'i~.•~It. CERTIFICATE OF DF Al'N ~ ' ' ~
• k•parimenl of Health and Rehabilitative Services triwT[ Flte No _ _ j ~ . ;
VlTAI. STATISTICS F L O A I D A RCGIiTRAR f No
i +'E OR PRINT oictwsto--NwME Lat SEt oAte o?awT„ • •o»,•. •1••1
_ _~i~V T _ GlILIIAM ZIEBFLL = 6 ~ fleee+nbQJL 4, 197 k
PE FtMANENT -
BLACK INK 4?Ct .»,n, »u:ao. •ltalc.» ly.•», wGE-1•v v>DI~ ~ .ua _ u,.ol. 1 N• CUTE d tlpN ir0.nr, o.•, COUNTr p OEllilt
aK ~ a•Kr• / patrr?• • •IMN r0a NH rO1df rM •EV 1
~ ~ k • A 22 1901 evgnd
Sr~f tOwN, OR lOCwt-I~i+
p-OEATN W+IN c.r tr,n MOSMAI Ot OT„tR NSEIt~11pN-H Ir ..ot fa..fa, a•w a~an~..e »w+a.
/V ` ~ Vur• of p r0
>e Me.C6ounne ,a yed re Jameb Ho~,neb R .tArta.C Medicae Centeh
f SiwTt p W/M .r wt w Y.a . , CITQEM d w11Ai COVNTEIr MARt1ED. NEVER MAtbED. SUR,/dtNG Sr'OVSE w rrf. o1H r.+f» »•M \
/ Iowan D. OIVQRCE 1 tncrr 1
.Ialoa»cc . W.i,econbin + U.S.A. annc.ed ha S/ounguhe?t _
-.e.t oeee•sao SOC~AI SEC'1RITr NUWE! tISVA? OCCU,At10H ,t.~•, aro a rws oo•r o11a..1e roar
a~. ewD d RuSENEis OR tNO(ISitr
,...to r N•Ir
o«. ••la r - oWa.r4 un, Mr r a1n•af 1
399- l 8-3200 Ac~nin,i.b#hatco~ Re~tih.ed ,>e Pub~ftc Schoo.Cb _ _q_
Ittcl•.cl a+WM wa1N Cr• trlaa SittEi ~0/
tISIDENCE-Staff COUNTr Cnr,iOwN.ORtOCwTtON
1 Va(r• 01 rp
F.Coni,da t.D B?Levand ~ ,•c Inc~i.art Hanboun Beach yeb t.a201 HQhboh P
/ATMEt-NwME IIW r.pOU L!1 MOTIItR-HARDEN NwME •rft r.0a•t W
h.n # Z.Lebe,P.t U?w4~ainab~Ce
1
IN/ORMANi-NAME aaARING ADDRESS ~ umn oa ~ •.o: ao, cr• oa•O•••1. at•n, RNE F.ton.Lda '
ha t~.ebele ,~01 Hanbon C.cty Pa~iltwrty,A107,Indian Hanboev~ Beach,
?wti 1- DEwnt WwS CAUSED Rr: ttwtER ONir ON[ Cwt~E E'Et tEiRT EOt NL AL w1~0 kA tier oraa w «.+r' .
Ir.rel.n c•YSi i
• la Ventricular Fibrillation ~
,
.IrICr O•oR ¦IaR q t+t _
Irrl H•Ia t•YfR IN, twf K,, W •R • co»saoua»ca a.
a1•flrD trE Y»N!
a•I»O c•VaR l•at +
Itl
,ARi M Oi11E¦ SIGNUELwNT CONOITIOMS: co»aea+a cor+w,ro.w w ofa. am Iwt aautw +o c•YU oonr w ..n . w AIAa1ir t• rEi .aee nr.lwas eor.
Ina Oa rOt YNaH w Nnuu»r•6 fJ1YlR
p ~RA,11
,R. No ,te-
p;~„6Wy~Et ,.GG~1~,
p~tp~ w 1 tort», w•, \I.a r fqu! MOw INNIRr OCCURRED 1 frna r•ww o. Irwn Ir r.n 1 oa ratn a, Inr la f
at0•aK/0E, Ot VuOE,ttRawED
~
M 2pp 20t M 200.
INJVRr AT wOt1E i1wCE d INx1Rr •t row, Lar, suer, •.c•oa•, IOCwT1oN 1 atnn a a.•.o ro., ut• oa Corr. at•n 1
Iancln na a r01 oNlca aoa.,aK. 111a(M•t
700 201. 20R
CEtiNKAiIOf-l- ro»tM o•r - nu ro..wl o•. •fu ••+o ua, a..~ ~r/wa •IM o« / ow/o~ wt .el. trf pEArr Occuute .i tw ?uca. or wr-
,NrSKIwN: rOrw oar nV ap• •n1a N•M. ,rp11a, C•n, W, tp qt-
. an»o/c t11t 7- 31- 78 TO 12- 4- 78 DID 12 :25~ ~ r. aaoa
?,r ouauo •aor 21D ~ etc - - 7 2f0 2,•. to tlr uwsfu.
• ~
CERTMKJ?iK>re-R•EDICAL EIAMINER Ot COtONER or Iwe a•s,s o• ur rpY, w N•tr +»E OKao•rt r•a ••prw..tu N•. 1
ta•rw•l1Dr O• W a00• •r0/Oa Irt w••ft/G•Ipr, W rt O•WIO•,. .
M 270 •wr12- 4 e•• 78 tau 12 25 P• Ra '
C , pa•M OCCVaalO o» w O•n •ro e11R to tr c•YSR Ia, a••IEO .
22i
CERDEIEt-NAME mn a •ar.u----. S,GNw - wa a• utu ATE SIGNED IrO,•w1. tl.•. •a.al
rk Timothy G Poirier,M. D. 2aD 12-5-78
F«m sae. ~„~imo°~i~ ~f'~oirier,M.D. 20~"IE«`~~eridan Rd. `II~e°Y~ourne, .Florid 3290r
t ,9n, tII? tUt,wt, CREMATION, ItfMOvwt EMEtEtr OR CE:EMwiCHr-,IARRE lOU1T10N cm a ao.rr sun -
- ;ea OvwS 1a•aela••
° ' 2.. 'on KD. P.~ctti_ncm~ CoabJ_ Inc. 2.~. Bh.evahd Co F~oni.da
.i. - DwTE ,tor... w•, au1 fuNEawt HOME-NwAaE •ND wDD+t[SS ,s.nn o. a.• a r0. ut: of to.», st•n, aN1
12 7/7g _ln. Sough Bnevan.d Fun~la,C Hune P.O. 1346 Me,Cbounne F.Coni.da 32901
' EWE It f- Ai tEG'S A7!-SIGNwEVRE ) ~ O•tE a~~j IvEO ar IOCN aRG13~•!t ~
1. A„t..__~2159 ~~s.~,_ <; ~ ,(~~+c?~~E'y 26D.lW.c~-,}..E~ , ~ ~
-
~ I HEREBY CERTIFYa1I~~"ABOVE TO BE A TRUE AND CORRECT COPY OF THE RECORD ON FILE IN .
THE LOCAL REGISTRAR'S OFFICE IN THE BREVARD COUNTY-HEALTH DEPARTMENT.
('+ot valid. ,tinle:~'~~ ~ as of •the Brevard County -Health Department is affixed.)
t *I
f's ',r.af ~ ~
1'_,~j~
s,K';:s~;~ ~'!~FLED AND RECD ~~cl ~l~~__
t ~`ff~~ S'. LUCt~. COUN - • Local Registrar
- 1~ =LL~RC VCRiFIEO
- ~
, _ D~C~8 9T8 ~~9 EEg ~ ~ ~ ~ _
Date & Seal - Deputy Registry
CLERK CiRCt'IT COURT
D. GENE ROBERrt= JOHN HURDLE VAL STEELE LEE Y~ENNER JOE WiCKHAM ROBERT L. NABI?tts R C WINSTEAO- JR.
Ho.old H. ColdnwEt
AttORNEY-AT-LAW E>
8025 S. fIdREW Ei,ry, ~ - .
Pt. St. La1C1R, Flo. 33452 ~ ~ - . ^f . •
~ -
c - ~OOK~ !'AGE~7~
y
'Df..•. - -
=