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HomeMy WebLinkAbout2478 ' e F . / ~ - ~alm ~ea~cli Z:ouiit y ~e~.ltl~ llepartmeilt ~ stat~ o~ rlorida CERTIFICATE OF DEATH '~5'`82~ Depactment of Heallh a~d itel~abilitalive Services arwTe F~~t No._ - V1TAL STnTtsrics F L O A I D A REGISTRAN'3 Ho. ~MMI ~~f1 ~X ~AfE OE DEAiN • rCwrw, 0~~, rt~~ ~ OE~EASED-N~M! PE OR PRINT f : 1 ~~O 19~ vERMANENT ~ ----------S.VPJt.Cff-- _ S~.~PA HLACK INK RACE ~N~1I. MIGW. ~IYI~~:~N ~w,.~ -~wGE --us~ v..oe~ ~.~u vw~~ ~ e~. C~ TE O~ ~1~TH ~.a~•.., e~.. CWNir O~ OfATM ~c ~ tiruw. ~ :Y/U~Q s.~~«o.. nus~ .wa w,s .wu~f ~ ..a . r1lRP U 191~ ~Q.VA ~I~Cli - - ~~---n ~r M THER NSf1iUT10N-W~ME nr .w~ nrw~. s~nn .w »wu~~. - r~..sq~ c. ~w f MOS Al W O cm. ~ow.,. o. ~oc~uoN a oe~t„ ~~~~s.'... o. ~ :~P.A~ ~Q.~/12 Q('.C1C~t YP/J r~ -s~. 1~1(!/L ~4 ~~04p q,~ - - - - - - n . ~ S1AtE Of W~1M ~u wo~ ~w v s~.~~~~ UTIlEN Oi VvHAT COINJTRY MAttlEO. NEVE~ M1Alt1ED. SlI~VIVN('i Sr'OllSE ~~r ~m. on~ r~iw» wW ~ cow.rn ~ wi00wEO 01vOKE0 ~ cr. ~ t / _ _ Q 1~_ _ .es~a..t~ ~ • ~~t G.(/.7.[. l\7lOi//.C- ~p,p/!!~ ~ U•S•A• w _l~~P~ ~..tlf O!(1~31~ V I .~o ~ w~~w SOCIwI SECUR~ir NUWER _ _ USUAL OtCU?~1~ON ~u.~ ar~o o~ rJ~a oOr~~ OW~G rott M 4NdD O~ WSWESS W INOUSifY i c'u~~ID ~w ~Oti~G l~rf. n!w M~~~NlO ~ SVWO~ w~ ~,,.,v„a.. ~M „ 253-~4-~S2~,t'i u.~~~an f~c~lm G~eadt o. ~es o~..ce st~we - - - ~ - - .c..~~s~a~ / wyw un ~rm SI~EEi AND ?Ml~Ef RES~DE?~CE-Si~iE COUNir Cnr, tOwr+. OR tOC~t~p+ ~ Yf~v ~ ~y !.~[/iW[.GL I~UNJ` ~eQC7L ~M /~[,.V~p~~Q L1QQC71. IN ~P7 IM ~I`~ AV~/~Q - : Iq f~TME!-~luwE nn~ r~oou ~•v MOTNER-AMbIN N~ME nu~ rroa~ ••s' i H.i.l,tvn .S~.~ze~ ~ita Aredeir~vn ~ ~s 1?NORNUNI-NAA+t w~wK, AOG~fSS ~s~u~~ o~ o.w . c~.. w w.••, s~,n. rr~ ` .l~.i_e S.ihe~ //46 Hveiu~e ~j~ I?~v.i.e~a 13~z f.G~ir.ida~ 3_~~~,~ .u ; IART 1. OfAM WAS CAUSf~ ~T. (EHIEt OfdY ONE CAUSE IEf lM![ f0~ (oJ. Ib~. I~NO (ciI tltiUw pr~~~ uM N~M ~ 11 rrwdf Cws~ - - - ~ , (~l D' ~ ~ , • • u ..a o ~ co~«no.s. u •.n. _t rMICM c~~~ ns~ ~o ~ 1~1 - g~ . - - I~r101~1~ C~Yf~ i0f, ~~O. ~~1 ~ COMS~OY~~Kf W i ~ ~~~tIMG YMY~R ; a~Ne c.vw ..s. - f (c) w.r - ~ MIfO~S11 M rE1 ~en ~~»e~..as eor- ~ f~fl ¦ O~ME~ SK,t+NiC~T COt~~Ort~OtaS co»ano.+s co.nM~m..c ~ w•r¦ ~u+..o~ nu~ w c•vu un~ ~~m ~ ns ~~•a~ oNOtiiw~ w~~~•u..~NC ura Z ~ 1 v ' ; { ~,.~eW~ 1•CCIDENI, SWC~6f O~ ATE ~-NJURY ~ rOrtw. 0~~. ~ NOIiR NOW INIUl11 OCCUftfD ~ Wr1~ wWtl Or ~ww~~ ~w ~~ft ~ O~ ~~~1 n, ~nr ~ ; ! NOM~C~p(. p~ U~Dftl~1?~D~ i ~ { I ~ ~ IM l~A 7~1 ~ i { 1?W~~ ~i wORK ~IwCE Of wJU~v »ow. •u... s•an, ~.c~w.. tOC~bp+ ~ sn~n o~ o.w . u.. o~ .o.... sun ~ 6 11Ndn t~f M~+O / O~~K~ MOG . ~~C 1 f?Nt17 ~ € CERINKJ~iq~- w• ••o•:u~ o•• ••o us~ s..+ M..~~~~ •~~n o« ~ aoioro w~ na otwtM Occumn n~~ n.u. w. n~ ~ ° - •.re~ oe.rn .,.o,~~ ~ i o.n. ...o. w w.~ ut~ ~~1M O~~ T~Y ~OO~ ~N~1K~aN: ~j SMJ, M rt [r10o~~OGf, O~M ~ ~rtIw010 rwt 4' 1 ~ t01' C ~ ' ~ ! tl~ ~ + • ~ ' )N ~ ~ ~ ~ ~ 11• Ti ~ ~O ~w! C~vSt~fr auqC 7~~ MCI~l10 ~W~ 4~ ~C t__"~-__._. ~w~ Of(fpM~ ~~f ~W~~W~CfO Ol~O .o..r¦ o•. .ow CEfTqKAilO?r--/+~EOKwI Exuw?+ER OR COfONER o.. ~~s~s w rw «o~~ a a.M ea.,....na. a.~e wo• .••o~« WvIStK.~~OM. ~N o?w~o... a~.M oeew~ro o.. wH o.n .»o ew ro•~ e.vse~~~ 1~~ND M)7' M - _ - - S~GN~TWE ---o~.a~ o~ TD~ATE 1!Gt+EO ~+O.~~w, D~r, qJ~ 1!~ - - - ' 1 : C[Rtltl[R-NAME ~ ~ rn••• A I•[ j~ /1 ~2 ~ ~ T7~ •~1 ~~~fQ~ ~7]~ - - - - - L . -6 -~I----- ~~l~ inR ~ r e cm~' " h. ' i i~urv+G ADD~ESS-CfRrK~E~ 2 I r I~02Ut. L PlL :~2C,Ve ~ P1~ ~21171 P tOCwt10N o.. a w.~ s'•,~ Wt~wl. CRE~IiON. ~EMOvwI CWfTE~r O~ CRE~T r-H~M[ - :!le.s# ~'a,~i!i_Gea ~-~v~t.ida----- • o~a.l /cr,lm ~ 1e~r~ . - - ~w ? f ~e"'' - ~-Wq~ DATE r.. ~ ~~NE~AI : r~~Ml tOa~R[SS o~ y~ o,{~,.`./ !'~o"" _',•~i ~ f~• : ' :v N f- ~co,C t~o Y.». adatz~ ~ i,.i.~.~enu G'ea f.la, ~w A~ ~°"l3, l T~ - ~ fIMERAI fCTOR__yG? JUR( tM'~~'~~ wIURI rf O~tf ~ECf~vFO 1 I/ ~IG~1~~~ f v.5. #G12 ~ ~ 1 ~ ' ~ r 7N il a Fw. 7/76 ~ t~(. - ~ 19T9 JUI. 17 P!1 i2- 4 I - ~ FILEO FND ft~G~4E0 ~ ~1~ ST.LUC:E COU~TY.f1 A. ROGER P01?RAS ~ - CLERK C'.RCU1T CGUij~ Q' i I ~ I NEREBY CERTI FY THE ABOVE TO BE A: a~. • CT COPY OF THE ~~~ST ~'RAR' St R CORD~,7/ ~ ~ ; ~ ON FILE IN THIS OFFICE '..~,'~a;?-' ~ . : ~ (Not valid unless the seal of ,C~ie.•Pe1m.Be_ ah'•~fifity Health Department is affixed) - ~ ~ ' _ - . : y i - / i i • - ~ ~ . f~ ~ 1977 C.L. Brumback, M.D. ~ AUgUSt 12, ' • j Local Registrar ; n~ 2474 ~~';rat Bureau of Vital Statistics ~ 60~K312 P~~~E West Palm Beach, Florida ! 1`