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sate of Florida CERTIFICATE OF DEATH~
Deputment of Health and Rehabiliative Services ~ F L O A T D A aTwTt Fitt No.
VITAL. &TATISTICS NE6IDTRAp S NO
vPE OR PRINT OECEASM-NAME ~nt• weetf suf SEx DAtE d DEAtI/ • rortrr, a
PERMANENT ' _ CATHERINE J. NELSON :Female ~ SEPTEMBER 8 7
Bt.ACK INK RACE .ran, rs4so, •yeK•r rwM•r, •GE-usr u«w• r n•f e.wff / e•. CwTE d NqN trorrr, e•r, COUNTV d OEAtN
frc. .vfcr.a wtrro•• rnusr rof eas .lows ww nut
White s. 72 w x •-Dec. 1 1905 Palm Beach
Cllr, TOWN. OR ~ 11pN DEATH wslN trw arraf MOIMTAI OR OT/IER RVSTn ION- t r rqt rr frtwe, 4M stwft .rle r.urefs
I S sN<rr qs a r.o
>e Lake Park tt. Yes ,Q 750 BaYberr Drive _
~ STATE d BRIM rr rot w v.s • . r•os CITIZEN d WHAT COUNTRY MARRIED, NEv[~
MARMEO. S1lRWVNG SgUSE Ir ors, ons ruee.l .rw t
~ cowm r wIDOw(D. D t sncrf t
a~•~ . Vir inia ,USA
.•.lo w ee•er SOCUU SEC'JlITT NI%WEf USVAt OCCINATION
~aa a.re a tr0er eow ewrro rwi or xMlO d suslNESS OR M+IDUST~II
~ccunq w trOesrrrf: trf, Pfr r tltr•fe t .
:~~'b"~ 263-76-5986 Housewife pwn
.n..ssnr RESIDENCE-STA/E COUNTV Cnv, TOWN, OR LOCATION wale! cr? trr.rs STREET ANO
tsnca. to a rq
t.e Florida tfe Palm Beach ,a Lake Park No. 14972 Palmwood Rd.
/AT1R2~-NAME rust .roost us? MOTMTR-AIAbEH NAME rlpt weer! us.
is Norman McIntosh 16 Ann Schneider
1?afORMANT-NAMME MAR.RiG AOORESS utpft w e.t.e. rq . cm M tw..r, saw. srl
t,, Ja Nelson 14972 Palmwood Rd.,Lake Park, Florida 33410 '
?ART I. DEA1M WAS CAUSED sr~ I[NTEt Ofvt? OrJE Ut/SE IER Tr+E IOR hl Al AND I<~ • s r. w
IR. twww Nttrafr OrNt w es•r.
• lel IK~S \ /1G/ OCJ~/~o ~ C7 C/J
coweators, a •rn j~ti,,~Q ~ (rs~ J ~ C ' ~
rrl(r O•to etsf rfi (11 ~ • ~v~
rrrf er•te c•esf ra, ew q, ee •s • CowafOwKf or:
sf•uro trs~ereee• On;..,
arse GAUSS ust +
tcl an ~
~ ~ f
BART R OTHER SlGtffIGUJT CONDITIONS: corNltrora cdrwUnrc q ever str rtet rune ro c•esf Orrfr w ru? . AAR~ RT ~A .fse nwNa4s cw
7C r ns t w w eeffrrwtrro ueaf
Or eeAfM
ca r 19e 'ffo tRo
ACUDE? MR ~ t .corr. e•., n•e s
O! fl/O~tERMMlO MOW iNJIIRT' OCCURRE0.t a rutty p~n rr r•st r oe r•af a, rfr to s
IOe 200 20e M. 200
INIURII wT WORK MACE d RVIURT' •t rrOrf, r•u, stMft, t.cgn, IOdDON , s*efo a e.t.e- rq., cm oe to~rr, stew t
esreun ns a riot owrp ste4.,ftc. tsrar.r
20e I0f - 200
CERTNICIITION- rotor e?t riu rprw e•t rtu •rre Oar Lr rrrr/Mff Yrn Or 1 er/ero rqt vKVr M 0lAM OCCYYlO •r erf rrA<f, a rtrf
effrsscuta• TO rortw e.• nu sow uns ef•wr trowt e•w, we. ro ttu wsr
. •nerefe errf p p r~
2ta wce•uo rwr $ 'l 78 1 re ~ 8 ! 8 rc 9 6 8 ra `d {awl' ..12.55 `MDr"O4f' O1"
to ew Wgftsr sutw
CE~TStICATION-MEOICAI ExAMRVER OR CORONEe~ or rra s•s~s a trr rrous a a•er rwf efcfsrrt .•s rriorptlr<fe we
' ff•rw•tOr M rrw epor •ry/4e tM rrvfsirG•rpN, w r. olrrrOu, rOrtw •Mt' rtu r10W
Of•M OC<YMfe Or IM e•n •re eYf q M( UYIfISI St•ne ~ -
M t2e -
M
CERTIFIER-NAME Ittrf oe rswn
elGf G ntif DA E SI(•i1'RiD IrOr.M- e•., qY1 -
__Antonio Rivera, M.D. ' Il _1 _
MAa1X' ADDRESS-CERiUIER twu a r e un r•n~ fa
Fo„tl s,~, no 1119-~0. ~la~er Dr.,West I~a~m Beach, Florida 33401
v•+ r9~. IR? lURIAI, CREMATION. REMOVAL EMETERV OR CREMATORY-NAME LOCATION an p ro~.r
st•n
c'aur OoCYa rsrlCrtr
Burial z.e Hillcrest Memorial Park :k West Palm Beach, Florida
DATE r.rorarw, w., nu. fUNERAI NOME-NAME AND ADOR[SS ~
sofa W r t o r.p , cm W ro•+w, s.uf, nr t -
2b Se tember 8, 1978 n. Hamm ~ Price 553-N1~oErthlake B1vd.,No.Palm Beach, Florida 33408
i1RVERAt `E~- At~ ~
TRA SIC,NAI ~ ~ OwR llfB~EO es fOCAt e[GrSte•~
7 r(R e ; a y ~ -
I 5~~ s * ,t'~`a .41A rs 4Y,~_~~~',i ~ri i ~ •s.• -
I -HEREB~'CERT?~~1f~~ABOVE~TO Bl: {A` TRUE`-AND~ CORRECT
- - t.~. COPY~-OF~ff ~!-.REGFSTRA 'S'RECORD'ON FILE ~IN_THIS FFICE -
r ,~~5 4;z~Not~ralid~unless the=~.seatsof~~the•Palm'Beach County F
~ - - " rm~ Hea th~:~Depar,~nerft>~is_
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~ ~ 3' ~C.L'Brumback,. M.D. -
~ ~ Local' Re istrar ~ "
rfc~ `'September 12, 1978 _ 9
} - ~y - ~ ~ ~ ~ - ~ ~ ~ Bureau of, Vital Statistics ^ ~ •
~•SEA ~ -~~~~~WestrPalm Beach, Florida ~ -
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- _vCfc COUP+TY, FLA.
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~gLcrct.,rn A~DerSo n '79 FE$ 7 lei r i . 59
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