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HomeMy WebLinkAbout0685 . , no If4~S;,~f1UN ~•~V999 - - •fATI U/ ~LIINOIi ~rr~i• WSIfIC1 NO. op ~ NEuMeE~tD 10 MEDtCAI. CERtIFtCATE OF OEAtH~~K N~. ' _ ~ ~~PA~~ s ~ c~. OECEAiEO--NAA~t r~eou SEx OAIE O CEA1N M~ e~~• • ~~+?M(MT INR . , aK.d.. uir,Cin F~ee~Lu.dl S.i~n vn ' ' d ' mu,~e a. anc~a~1~~_ : ..obuoller ~~:E ~.,~t.~tVO.wt~~u~ .~o~~r. AGE-.a, .~N Y A • A pAIE Of 01liH Irowtw.s~r.~i~~~ ~(ACf Oi DEA1N ~~r~ i •l~hl:TIOMS ~~G (t~u~l' ~~~tr0l~ 1~~t.1. rOf. . N~ ~ wOx~! . r¦ . : «u.r-~ s0. ( 2 : se ~ ~ , s~. ' A..~ P_ .fp . 14 I 1 ~l ~o Cu.~e~ . F tn.. ~o+r. r~?. O~ ~0+0 on~~Kt ru~Nt• • I.iUiol~~ ' rofa~~a 0~ o~.t~ •?sm ~~-N~ 1~ u rOt t~tr~~. ~~va p~cl~ ~H rvw~l~ ,b IuL~e~.t.vn ' ~ hn~e~.l.vn Nu,~ i_.~a.C ~ S~t1M~1A~f ~s~~~t o~ ronN• C~1~1EN OF WHA1 CO {dT Y MARR~tp NEYEt MAIfiEO. NAMt Oi SUfVIV~NG S~OUSE ~...~i~ ~~ri, w~p ' w~oow~o. avo~c~ o e. ~.~~in.v~..~ 9 .S. J~. ~o. m~a~tueri Mi.~i~~e~ Stute u~eit S~C1Al SECUt1iY NUM6ER USUAI OCCV?ATION ;~~~+0 Q~ wsw!SS Ot n+ot~l~n ' U S WAt VETEIAN~-WAt OR ~AfES OF EtVKE ) ~ aisi.» : _ 2~ ~ 86 i~'e.C~ emp.G~L~d Tauch.i~rr~_ :,k ~w : tkSIpENCE ~~~ta ; w~~~. • ~ ar~. ~o~w. rs. p~ w~o o~st~.t~ ro •~wsro~ t`o. --Tii~an ~ os+u..~i• ~a~ J.uin~~~~ ~ ~t~~ ru : ~..+..b? ~ ~~c ~rI2Atl.~ ~ l~e P~! ~ 1.. !'WR~ FA1HfR-NA/Nf •'~ti~ +~ooaa ~~sr MOIHE!-MAtDEN NAM[ ~~~s• ~~ooai ~~a~ ~ ~s aa~6 . J.im•hvrt ~d /•'ioic~ . ~'udw.L i ~NfOt NA1U~E . ttlA1~ONSM1? . MAIpNG ADORESS i~•~t~~ uo ~o o~ ~ e.. un o~ ~or~. s~u~, f~?? -~~o. L R ~~~b~~~. :,~t K~~ 9.1. 6~933 ~ la. pEATH SEO Y: [a~*te ora. C vat rV ura ~o~ Id. 1~l. ue Itl) ~ai. ~w w ai iii o4tr ~A~~ I WMl ~f~ CW1 ~ei ~(S7~.b"~G . - ~ oVl 10 N~ COM~IOWwC~ M CJrn.~~J\S. ~A~, .,.a • s[ ro Ibl ~~~~~1' ~ r - -`1 f- ,..,o~.,< o~~ ,o ~o., ~~.«,.--L v~.a c.vsc a•s.. ~cl - ~Atl u. OTHER S~GNIiKANT CONdi1pNS: eo~o~?or, eo~+.nu.«e ro a:... w, ~ei.ne a e.+.r a~.. w~ur ~ w~ ~.U'p?;,r ~ti. I~lSIw01 . ~ N~~. ~ Nr~~~r.Y lM~ s~ e~~.. - - - 19 . RU ' 19b DAiE O~ O~ftAi~QN,tF ANY ,MA10! i1NpINGS O~ O?ERAiION 700 ~ pb - iAiiENOE~ THE MOtitw.D~q~~• . rortw.on.~~u •rOI~S~S~aww~ rowr...o~~.~t•~~ .HOUR O~ EAIH OECEASED itUM- ) ~ ~p ' o~ 2tb. - ~ ~z ~ ' ~ ~I~ ~ I l -/a ~z~a : o: ~ r. M. I('EXT/FY TNAT TY1 E AF.ST OF' MY KNOtti'Lt'DCE TN/S Dt.'ATII (~CURRtp NOTE~ li AN INIURY WAS INVp~VEO ~N THIS DEA1M, ~ ~~N Tl/E DAT6. AT T/~I6 AND PI.AC ' AND PRON TH~ CA S!C(S) STATt'l~ 1HE CO~ONEt MUST dE NOTIi~FO. SIGNA!U!E , DATE S~GN 1ror~ . o.~,.c~n ,1(~IN(~IS t fN5 NUM ~ ~ no. ~ ~ ~ n l v ~2 ~ . MAII~N AI) C 1 1ER sr.~ e¦v • . e. c,r. . ~ vr.`-- :u n ~ ~ % / ~?-v . SUlIAI, C!E AliO . , CE EiElY ~ f0 - E , tQ(;All a+. o• r srua . GAIt ~.o.rr, e~~..t~.1 tEM VAl ~tc . z.e_ cvu.czl"' : z.e f a.i~.v.i.e~c~ ; zk Kcr~t~u.~ .7.LLinv.i.~ ~ z.d. l-~-~ , fUNfRAI HOMf :-TiAAIE s»aa+ .~s +vMw o~ ~ e. n. •~rw s*.« t~? ~so ~ cr~tvn. ~ J on. cute~u.~ Hvine 1 I2 a.~.t l+~ u.~it.in~ tori, %~¢~t,t~ :I,(~,v.i~ G~~ ~4 ~UNEtA Ot'S S~GNAI~JlE ~ ~ ;~UwU~I dtECtp~S 4/W10~S IK~NS[ NUM{(~ ~ ~se ~ r ~ ~~~L - y 7 ' k _ LOCAI ~EG~STRAt'S 51uNAlUfE .pATE Rf l~ S~ IC)fAI lEGIS~fAi t..c.•._e.. I / ~ . ; a~° ? ! / . ? ~ ~ i' J ' ~ 2 b. ~ January 20, 1977 ~ VR 200 (1l71~) ' IIIlnoif Osp3rtrtNe40t OIIC NN1lb ;j~f ! Of Vlt~l RKO~Of +S~SEI+ O`~ ~vb S S~~r~7~tU Cl~hHC~tE~ ~ ! ~ g i E E -~,r?~~'~b~.~ ~~,::w`a. . _~_:r~ , .,,~RC,~t'T,"~.,'::-- CER IFIEDTRk~ECOPY G~~~~~~E~tz:'"'':'~'~ _ , y - ~ -'~L-~K ~i - .'O ! - , : y~ , ....I ' . ' - I ~ ~'f . / • ; t ~ Ot1l, I[OM~K1~K~ y:~ ' w..J " ' ~ < ` . ~ ...:t~~4 ~ r i ~ ~ ~ ~ ~ : ~ z ~ . . ,a4 , ~ ~ w~~. • ~ . . ' . ~ • . ~ j ~ ~ 448999 ~ ~ ~ ~ ~ ~9~9 Jv'; 25 AR~ ~ ~ 22 ~~t.p aht~ coho~ o ' I ~LLUCIE COUitTY.FIA. ` ~06ER POITRAS ' ~ . ~LERK CIRCUiT C01~~'~ . C RErbi`D'.: -!=l=~-~• F ~ ~ f 3 ~ ~ . - '~I t,~ti,,~ ~ ! ~ t ~ °_yi`'u'~ ~'S~S~s-~r3'.~~ Z.••, ' - ~ • ~ •t..~~- .r.~, ' ` •..7~, • , ' ' j .i • . ! . ~ ~ . ' • • . - a ~ U Y~ 1 • ~ FiRQ