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IAA fORE1W SE4vICE OF THE 1MI?TEO STATES GF AMERICA
REPORT OF THE DEATH OF AN AMERICAN CITIZEN
American Oansulate General
GLadala~ara~.Jahsoos Mexico--_-May 4,_1977
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Name in fuU ~or'&e . Nolland..I•btt Occupation
,Retired • -
Native or Tlsturaliuri ..As~X'n .3.t~.Ql~lQ..._Mdx~Ch -7, ~,~Q7.-........•-. Last known address
in the United Sates .6?1..I~~~;3..~'.7.xea .C•A~4i~1A.-$~aGh, V~D,i,o~,F~.or.~,da .
Date of death ....._..~Y......._...._.~...._._.....~---- 09- ------X977.---•--- Aye 7Q..._.-
lll.~t41 ILrl/ 11lw~r1 171i~W.) (Yrr1 fA~ wr.rb u r+~ ?r ~.orrf.~u.~l
Place of death Unstated
IY~~,?rr uw-Urwll w IN.MW yr ?w.4 lC~y? .
Cause of death . Probaible, c I/:wetyl -
~t._ ~e..~Q..~e.;?p?x!atux~r. ~.nsuff~enGy.,.. angor
• u.rMd. •wlww Iw aVtraul
R~~~~~a..I1~R?'1r4pathY.. asp certified bX..Dr. _-Daniel Zuniga lmbledo, Independencia
Disposition of the remains ~it~~S?_I_''.1~~4i~o_.City•-for•.cremition. Z4~ A]~3c;'-Jalisco
.Mexico.
Local lsw as to disintemny remaiaa N/A-_•-
w_...---•---..._..-----
Disposition of theeBects.ZT7~..~~~O~y Q~_.W~.~4. u~~.gina R,-- Hott..._....
Person or official responsible for custody. of effects sad accounting therefor ..-Virgini~,.,R...I~tt---
Informed by telegram : -
MAYS ADORit7 IttLATIONSNIP DATt btNT
None -
Copy bt this report sent to: .
MA![>< ADDR~ 1sLATlONSHIP DATt StNT
Virginia- R~ Hott 621 Hibiscus Dr. Wife.__._----_--- ~-4~:Z7._...--
_ Golden Beach, _
. Venice ..Florida ~ -
74svelin~ or residing :1?uoad with relatives or friends as follows:
• MAID ADDRiSb ttLAT10NW{t! .
- ` Virg;n;a.R. iJott.. ._.?°~jjc,..Jalisco,--Mexico
---~+1i-fe---•----•-
Othes knows relatives (not given above)
- M~ waaasss
i ~ ~ - - AiLAT10NSH1!
~ox~..,A,._~tt-- --.X21..I~b~.&~u8..~'~------------------ Son
- -----Bea. h.~
r - Venice, Florida----------•----------- -
- Remarks: U. S,_- Passport ~ E545585 issued 4/2_9/74 cancelled and re_ turned_
.~fic'f3~ _~t~._._Secial Sec~sity ~n~unber_unlglown; receiviT~ benefits. CoPY_ _ _
of this report liven _to Social Sec~iri %Gliadala~ana. Death recorded at
f S~]dI?~1sl..G~.Yil,.:Reg.~$~y~-- Book__ 1977,•- Page-- 26/V --Act 51.
i ....(Continue on reverse it necessary.)
s [$F.AL] Mary Ann Kekich ~s~s..w....o .oN.:l
~ 1.~ ~r~cri6.d. -
• _V~ee- COI1Sl11• oI t1?t Ct/ubd Sw4~ o/ Awt.rtios
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This is to certify that this is a true and correct
copF of. this death certificate-Feb~raxy 23, 1979. .
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