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HomeMy WebLinkAbout0943 ! 45C~'780 t ' ,i ~ ! C6RTIRlCA16 OF G~A7H p l~ L O R i D A KATi /!lt NO N~.-' ~ liO . :--r= ---a ' PL~IaC~OR ~ Coot N~. fUAV !1[fIDtNCr ~wtr~ ~w.wa M..a u ~wnMw• n.i.rw wrw u ~ . ' 6f~-~ ~ n~tf F~ cow~rr • S ,~~._i.ucie ~ ~n ~a .r.w ..w..a a.a.. .~w ivw.~ e uNarM or e. ci ~u wu~« ....~+.e. a.~u. ..N. .uR.w ~ ` ~ to°r~ F ~i~r~dw..~«.~r o~ ; t1 10WN ~ ~ Yli NAY tlf rt N MMM ~r ~re~lr. Nw ~ Nrw ~r wwN~~ ~~~i/. SiREEt -----~,~i~~ n~ ~•aa.? - - ~ MOS?ItAI O AOCRl1f 1M'- 1@ ~ ti• ~ ~ ~ INStItYilOM ~~V - - - - .,1 - - - : M O IIIM) IYMNN) R IlYt1 OAT! (MsAI\I IM~1 IYNr1~ > ~ ~O C~~~<O OF i w r« Ci ~oia~in~ ce~t?~ biar 1 1~~~_ ~ p 1. {Ex ~COIOA 01 . AlA~tl[0!.N/r~t MA~~ f~. OAT~ OR ~Il?H ~ ACl~4 ~r ~nu ~ ra~ J•¦u~~ r~ wI~w4Y.01~O~C.~01 N«~ hl I Iw ~In ~ M fl iMrW ~ ~ j i M w s t Y M !'a e r • a, IN. Y3YAlOCCY?At10 2~'---t"~'-" ~ ~ W ~N t IM. R?NO Of WfiNlff O! IM• 11. ~I~tN?lwW fR~N ~ I.Mn ~wrn~ 11. CITIiEN OF 1NNA? v ~ ~ oust~r ~~u Finl~nd ~ couNrar~ , ~ R Y ~ -------_---'-"1.--~--- ~ _ j 1. iA1Ml~'! NAM 1~. MOtH{~'! MAIOtN NAME ~ i ~ u ~ • - - ; ta~ ~1tN.A~, M~ir i~1 N/N,M ~~if~~~~~ N. lOQIAL /tCY~I O. IL AODLEff MP~ l1aNA YR! ,{l~J„a Koistj,~^il._. ; ~Q ~ e w 1~. CAYf! O~ p6?tH MiO1CAL. C[RTI'ICA710N 1 ~~MTaw~~~ ~enirsw ~ g ~~q* ~~q~ 1. OISEl1f~ O~ CONOIt10~ ows~r ,?we erw»~ ~ ~ ~ ~ NN tK 1~1. 1~1. ~I~~CtI INWN~ t0 tM~~~~_ ,eutp`'..'~vn _nr~rii nl : nt'arn _i ~ ~ _ - - ~ ~ ~ AM1/0lCiNT OAYfp ! ~ •1'~u Ou~ TO (_ri Cnrnnorv Se1 prns.i ' ' ~ ~ U1. s~ ~t M*~. If~?W srwr(l~ fJ ~w*. Ndw~ $ - ! - - 3 wd u~asN p~lrn. +fN Wsi~N MrN f~/ ~bb t £ y u utA..l~, eH.t ~/,{t~w~M+u ~I W~1~/ Nw ~ DYE 10 e ~ q. o p e~w.~ r i A II. OtHi~ N~NIFICANT OONptilONS ~ V- - ('J q Nwi lwtA. CN~~fti~M Ma htfR/ M W 1wt1A h! w~e I B { H . ~ IN. DAt! o !1. ~ulonrt .fi M None ' D Mo O : ~ ~r.+..a~ ~ ~ uk o ~wu a...~.......~ ua tc~T,ro~TOw?, ( uM ~:.~~r~ ~ ~I~. ACCIDtNf ~ ~M~ MA A11~l/, w.K...~. rw...~. ~ a~.«..aw v,aau : ~YK10[ ~ 1. fIOMf l 1 fDyl 1 1~. Yl ltEp . 1 , ~ ~ INJYt~ ~ ~r~u~t ~~issu• , ; ¦~~a ? ?t s~~~ ? ~ i ~ n. t l?err6y ant)/ t/~1t j It!!!~Q f~ j~ /rp/11 'UCC ~ , JP~O. f0 _i:ar~ , IA~.. fAo! l Iru( :nrr Ihn d~~rn.rd ~ ive on t eti p~ sd ot ~ i m rv?w /M towa and on lh~ dale slal~d abn~~~. . . : ` ~ ~ ~ . ~v ~n•m. « aw? r. ~ - ~ 1k. OAtE l16NF0 ; ~j ^ t~bir t. Fi~, : 1 -1 fi ~ 2N. ~ Y ~ 1 A l Q~lW4 l1~. pAn ~1~, NI1M! O C~IAEtE~1 O~ C~lMAtO~~ . IOCAiION (G4. ~we. ~r tmrel~l Iwlale) non, ~wo~~ ~..w,~ # - r ~ " . Pit ~ c ~C,lerid~ : DAi~ R~C 0 LOCAI ~NIl1~Al'f N~NATY~/ t1. fYN~I pll?!C'f0~`f ffONA1Yl1! ADORiff ~ , ~ -8- us. os a^uF~ D b d . . ~ t t I~rsbr prtify thi~ to bs • rru~ •nd cwrect c ' `~O . . ~i - oPY ~ 1M Lot~~ , i Rpistr~t'~ record on file in the St. lvcF~ County Heatrh DspaR• - , rtqnt at forf Pierc~, Ftorid~. , ~ ~ ~ ~ ~ ' Z~~ • . ~ ; ~ _ (W~rning: Not velid unless rei~ed ~esi of Ihe St. Luci~ M~~,,,ias~ - •,j ~ ; - Gounty H~alth D~psrtment i~ effi,c~d.) F+lE6 n'~~° t~qA ; SS.t~~ ~P~ ~S~ , ~ ~ RCGFR ` N. 0. MILIER. M. D. CLEF,K ~ _ ` j Gountr N~~t~h Offic~r i[oc~l pi~±bqD~'fPt't"~- , ~ • /T ! * V / : ~ / . F . . ; , f r~' V • ~{/~y LoC~) R~o~drAr n . . . ~ . . ~ ~ ~ /V ~ / ~ ' • ~ . L ' . ~ 8n~~ 3~.z fac~ ~ ~ - - - ~ .-s - . _ _ _ _ . _