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HomeMy WebLinkAbout0382 II 443104 ~ ij • ~ I ~ ~ Palm B~each ~ount t~ ~-iealth I)e ~rtm~nt - . - _ . - ~ . _ st:~t~• ~~t Fl~r~da CERTIFICATE OF DEATH lk~parUncnt uf Il~~ltl~ and Itchabilitativc tiorvir~x ~?ATE i~~c Ho vrrn~. s•rn~ris rics F L O A I D A REf.16TRAp S NO ~ Q~ 3 ~ V'E ~)H PRINi OECE~SfP ?~vwf ..oo+~ ~•~r rSta U~~E O~ Ot~M o.. .eu ~ ~~FRMANENT ;1~f11F~I . 'tli.I.'~:It I: ?,:il~ j,. ~k~v~~mb~r 1 ~9~~• lSLACK (NK f~CE .~w.. ..~a~... ~.o~... ?GF ~ ~.v u~. , .u~ u..on ~ o.. i C~lt Oi ~~~IH .,w..~. ~ - -l~ - . - ~ ~ - ~~t • fr~(•~r ~ ~~~~wD~r ~•~~~f~ u r0f i D~~f ~OUtf w •1~~ ~ O••, iC~ll?~llti O~ D~AIN ~ ~:hitr s~ _ 77__ ~u~ i ~ j ~ 6Junc 5 1 O1 ~'•~lm I3~ac!~ C~tr rOw?~. O~ tOC~t~O?~ 01 Ol~tH ~~~oe c~n`~~.,:~ _I~ -i-- / O ~ ?qShlwl O! OMER NS?1IUT~ON-N~ME ..or ~n.~~ ~~q~• .,,o „u„~~~ , V ~.~c .~s o~ »o I.zk~ l:orth tw ,a - Doctor~s 1~os~it~1 ~ ~ S~~l[ O~ ~~~iN . - - M - +o, u ~ . ~Crt~![r~ O~ wN~t COW+Itr MAf~yO. NEVf~ MA~hEO. ~SUtvrv~+G SrOVS! ~ ~ w.e ...w~~ ...r~ . . cO1"~~• ~ w~00wf0. OrvOtC~D ~ vec... ~ ' , T~ lci ~ ' 1. ..ru cecaf~e ~It113[ld 9 fo ''arrl~,(~ I ~.LI~~.~1t1"11 1i~ a•n. SOCI~I SEC'I~IT~ NUMSfR VSV~I OCCU?~I~G?~ ,a.~ ~~.o o. ..ou oo.+~ ow~..o .uae o. [u+0 Or WSwESS OR ir+OUSt~r _•wo rwa~~.c t.e•. u m•~eo ~ a~.~ . ..,~,»<~Nb.. ~y'-"t~~'n --_Chl~sffrur ~ . F ri~ at~~ '"1fO" RlS~DENCE-SiA?E COU?~t~ C~Tr, tOwr+, Of iOCwbpH ~..t~o~ c~n i,.,~~ ST~EEI ~ND NUM{Et ~lori•~s P~lm A~ ~~.~~,...,.o..b, - _ _ ac~~ I ~Ice ;:orth ~ Y~s ,k 1 ~33 ~ f' 1~ ~nv~~ ~.~rth MMf~ -N4M[ .,,op~ i.s~ MOiNEf-MAWfNN4ME aq.- ..~oo,~ ~.s~ ,s ~~.,ttl ,~I~JIi1Fi~~t1 ~e ';it7~)t'rltl'~}~~.^ ~N~ORMANT--NAME ~ A4MINCs A00lfSS ~f~n~~ o~ o.ro. cu. w~o~.+, s,.n. i.r~ ,.A Tild~ "'~ill~r 1733 ;lv~. I,~'~tr ~:oi•th r1o2'i!j3 ? ~l<<~ ?~n ~ pE~M w~S CwUSfO .•no..... ~ ~ENIf1 pN(1 pA1( UVSI IER lW( !Of (o/. fbL (~l) ~~n.pw ort~t ~r~e M. '6 __~-WWOUhCiYf~ . . . . ~a~ ~ ~~wi3T ~7~~~/ / ~ ~/•!'eI'1-, S~•J? 7 C~/'tr ~ _ 1 I~)C~7/~~ COMO~IIOMS. •N~, ~ ~ v~~tr G~tf ~~f~ t0 (S) V ~r~lD~~~f t~~1~ ~o~. I _ _ ' _ 3t~1~r4 Iw~ Vw~~~~ O4t t0. W af ~ CO.~UOWKf W - _ . _ . . _ ~~ING C~V1~ 1~1~ ~ ~t~ ?~~T ~ OTaE~ SIG?~VKu~T CONO~ilONS co»ano..~ co«.~~~ut~.+e ro w~~. ~u~ ..o+ ni..w .o c.rs~ u.e~ r.n ~~o~ wtltO~Sr H rES .r~~e n.,e~wes co. ' ~~f O~ ~O~ 4o~~fo ~w qqb~r~rG Uu O~ Ol~IM P~ 1•CC~O[NT. SUKIOE W T-/A~~INIU~Y tl.~ ~?O 9t~ ~R7Y~~~ a ~ r0'a1M. O~• 1~~f 1 IMOEfltlMINEO ~x NOW IN/U!Y OCCUt~EO ' er•~~ wtutl o~ ~w~v~r ~u ~ o~ ra~~ ~rt~ ~ l~V~urtl x-.~ ~Of Mc M 2~'f . INIURY A1 WQRI( ~IACE OF IN1U~ •r .ow. ru~. SrMt~, ~~(tq~, tOCAh ~ 1 fNGn q! O~ ~.O • O~~Kf YOG .~K ~fMC'nr ~ ~N . . s+~Ut O~ O r0 . Cn~ O~ rpr.~. fLq ~ 7M ~1 ~ CEnirK•rq?~_ ~ ~Nt31C~~w~ r0'+~.~ e.• ~ qu rOr.1ti o•• •e•• •MO us• f•~ rw. 1~ •uv~ ow ~ o~0/oro wOt ~r~wr nK OMiN OCCU~~tD .t r.i ruu. d. . TP ..o»*» e.. ,w u~e. ~~q~ N~M ,.ou~~ O~q. •..D. M m~ n •ne.+o~0 / f / t p~ r. a.pr~~pW c , :~a DICI~ifO ~~Or~ ? VI ~ 21[~~'.~~ _'~~,1' 71C ~ CERiIf A1 - ~`~ti r~._~1~_ :1~ ~ ~~I~I ?leri; ~ )[~M ~Or+fuufni~St.•~r K ~-w~EDKwI E~~~urrER O~ CORO?~E~ o« r.e 4~,+ o. nn »ow o. q.n. oaeoe». ~.f .~p„o~„cw oe•o e¦..~....o« w n.e wo. .,.oioa ~...~~T~e.•~o.., . o.....o... ..o~.rw o.. .~.r ~.ou~ ~ O~~r+ OCCV~~fD p. n.~ O~rF'wD DUf /O ~M C~vSI~l~ 1•~t~0 ~ _?a _ M i]7p . CfRhiiER-taM~tF mn o~ r~~w,~ ----=---TS1GNAi i ` . wo~e~ c~ ,nu ID~TE S~Gi~iEO ~..o~n~, o....t.~.y 4 ~ - _ / f~.~l~ ~~1.~_.~.T~_L~_L~~,--._ ?lb__ .`-_13'~/~~..~~~~7;L_`~ ~7Y.~6%~ ~ 7 ~ . ~ua~ADORESS-Ct~ril~fa l~.~e. w o ,+3'~- ~ a ~o~ y:~ . ~ -.eS v,.rm gtj, T~A Z. ~ 7 / ~ :.i~~/~ 1 ~p ~ ~ .1 vu~ , iq+7. 1~ / ~ ~ L~ ~UlIAI. CREA4A/pN. RE/M~VAL CfMETE~r OR CeEM~IO~r-Nw~ ip~•i ~ o~ o. :o~.. s...~ +~ts OOGVS ~f~fC~n~ I ' f46+71 ~ , 2a~ r~ma~ion ?.o rallac-~:~ Cr~m~toritun i o~1r---- - 3`- - - - - - ',~'cc :~~rt~~, "]orida O••1~~ ~ , fUNERAI HOME - NAM( IN~ AOORISS ~ f~~~t~ O~ ~ ~ D- ~+o (~~r O~ ~O+~~i" i•~+t, t~I ~ ~ z.~~ Nc~c'. (~I7 ~L y~__ ~ Paan~nnn T.~'r,~ si~e Cha .1 I.~'ce ':orth '~~l.~~ri~~ ~ ~U~+ER~I DntEC70R--S~G o - tEG r¦ r~u o~~r ~ece~+~o ~oc.i •tcnnu ' ~ . ~ <<n ,a. L'1'T/1 . [S ~L-~~~s.-. - 's - ~ Q x,e 1 - - _ 3 ~ t ~ , I EIEREBY CERTIFY THE AEOVE TO BE A TRUE AND CORRECT ~ . . COPY OF THE REGISTRAR'S RECORD ON FILE IN THIS OFFICE ~ - ' _ (Not valid unless the seal of the Palm Beach County ~ Health Department is affixed) - ~ . , - , ~ -i ` ~ ~ 'a: :77~~-tzc~~ 1 e ~~YT7 , • ~ • C.L. Brumback, M.D. ~ ~ Local Registrar _ E ' ~Vovember 7, 1978 . Bureau of Vital Statistics 3 SEAL _ West Palm Beach, Florida :i _ ~ '9t9 -3 I1~ 52 : i : f REO AtiU ktil:0~t 0~ SL UCIE C4~Ar R~A ~ I' ~~~~E~~i ~ ~ LnW OFFICES aECO~ov~a~~o - - ~ _.4MM1 AND MARKE i ~ ~ L-`. KE WORTH. FLORIDA I~ ~ ~ ~ 3051 865-6464 ~i ~~~10~~ ~ ~ r . .:f: . 1.'~: .~~i'. ~ . . , ~.i4' . i 7.~:~- . ~ - G k JO~ ~ i~ _ r:~,- : , g~~~ ~0$ vac~ : , ~ ~ . ~ ~ _ r~< ...y~ ~^`~,r,~~~; i ~ c I ~ "~'.~~a~~~ a r f . '~rw.~,.' ~