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CERTIFICATE ATM ~~a~6~ - - ~
QIpRCEucrtl Ika~llr owel Rc6eM11ullrt $eer{re r / f'TATt RIL! ti0.
' I>tvE+7crv ~ Elralnl IF L d R I D A
iY?E, OR E•llNl 1N wwurar°rrarrra° "RE:Ei16TRAR•B NO.
tr[RR?At{lE1T INK EASED-NAME nut woeae usr SEX DALE CM DEATH rrorrr, owr, reru
SiE R{IOi00l i0t '
RlsTwgEors A es e _ 80EPSELL ' ~ l.F~~
tACE: rwon. avow. uucKwr wear, AGE-usr w+aa r reaR urorr i wr OrA~T;C+f WtiM aroran, o+*. OUNTY C+F OEA1R
• ex. rw~ u~nj) rwowar rrwrr roS. ern wuas rK .
. ~ NliJ.te f.. A k. { 1i-
OWN, OR IOCAI ! OEAIH oasaSC car awns HOSMTAE OR OTI+ER NSTITUT - 1 nor w urwR, art uuu rp ruwu )
{reeve re{ a aao
' STATE CM WiH r r rpr w ar.f.r., wart CITIZEN Of WHAT CCKlN1RY MARRIED, NEVER MARRIED, SURV1vNG In wuc, t:M rwgew tyre E
ost,ar rrewaau Illinois `°^a"") USA N Darr e~IMKYr/ EE. Elmer
arheer eeuaSle
ono. a oerM SOCIAL SECUtlTY NVMlER USUAL OCCUMTION lave eNe a wouc Oarte pWwa raosl M KIND Of WSNESS C/R INDVSTRY
occwae w waQNa eMr, Mr r N^aN r
,~r^^^~•°~ T!. 26 -41- Housewife - p?. Own home
uuarcr aroet
RESKlENCE-SUTf COUNTY CITY, TOWN, OR LOCATION ws~oe caTr corns SIREET ANO NUMRER
l rT flS W a1a
,yFlorida ,~'alm Beach Boca Raton ,{;~Ces - ,E..1125 SW 11th Street
fw1HEt-NAME mast -wool[ - usr MOIHER-MAIDEN NAME LLB 1Asr
Charles Middendorf ~~V le ~S
• IS.
INTORMAidT-NAAAE HARING ADDRESS rscccn oa e.r.o. ro., trn a rov.a, sun, !rr '
- ITr Mr. Elmer Soe sell U?. 112 SW 11th Street Boca Raton _Flori
` PAR 1- DEATH WAS CAUSED~~Yb ~ENfER ONEY ONE CwuSf PER ENE fOR hA (bl, AND (cJl rervner orser tar otr
~ , ti ~ ~ w or au e :
~J~, ~ ~ ^
waKa arve ose w - "ibl
~ rrrtaan cruse ar, ~ sue w, a as w eorseoaree ar. .
srr,tace ,Me eree._ - . r-
nwo torso usr ~rK,/evw.'C G.~~ `'"'`v
- - . lal ,~.t,.~y~~ - .
?AR[ R. OTEEER SKsNYK.ANf CONDITIONS: ea+a^a+s coanwvlwo ro Dual aw sort uuno ro t:wvsf emw N rut a adl AUTOPSY K YES vr.e r/wol~as e
. rues a rol of ewN oenawru+o
Ni AT I rOrrM, err, tort HOW INRltY OCCURRED I [rreR aunrre d argrer w tsar a OR fwRt a, act r•
OR IIr~IERMMtED
2 !f?. TEk. M. !'N.
~ INIURY AT WORK PLACE OF NIURY ar roast, tsars, street, rrcroar,
•"7 tucurr nr oa war aeacr rteO.,eK. esnearl LOCATION Isurp oa e.r.e. wo., car oa rarrw, strut
~ CERTYICATION- rOaela oar T[I1R eaearM orr teas rase asst srw a^r/rea utrE-aa Silo/NO rot raw M l1EAiM OCCYtlED rt Nt rust, o.a ^~t
PNTSKuN: ~j ~ rarta Oat riat root uric start. IwOtaa/ Oari, ar0, t0 R.e trs
r rre.+oto mt C% TO 3- 73 }t/. !te • to nn u+iii' ~
j l11. oeeuseo trot 7 !t?. ~ lO Me
CERTIfICw110N--MEDICAL EXAMItiER OR CORON[R: or nri casts a tnt tour o. Duna - tN[ oKeotan was reorou..cro oE.o -
_ ~ILWNwIgr d W! K~Of nND~Ot IME NVfStlWtgr, N ri OINIOr, rOM1a Wr Rnl NOU!
oeaw occtroto o.. ere Dan aro ove ro r„c uusetu atauo. ' ~
CERi1f1ER-11AMf etrn o. rrwo SK,NAiU~l styes ~ tRE DATE SIGNED t:torttt, orv. renal
MARYiG ADDRESS-CFRTIf1ER 600 Sou~~l°'Dix~e Hi hW car uBoca Raton Florida
!>i
% - bUR1Al, CREMATXN~, REHAVAL EMEiERY OR CREMATORY-NAME ~ LOCATION Uir oe torrta - start
;,;r"~#emoval _ N,.Highland Memorial Ce Waukesha Co. , Wisconsin -
~J ' DATE r vw oar, trot fUNERAE HOME-rtAAt[ K SS t sleep oa err-o. ro., etas as tor+at, sutc, rr r -
}E,. 4/12~~ ~ I'•raeer, Ii . Fed. Hwy. -Boca Raton,l~la. 33432
y, S. X612 f!>`tE!_aS D ACTOR-SrGNti \ PdGI~TTtiIP- vr+A ~ ariE Re,tIYEa 1Y AOCAe "61StRwR' ~
1970 fS?_ a--~ocL~{? ~ }ter 't ~ Te?.
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~ l - - - CERTIFIED COPY - . ' - - ~ - - _
2 hereby certify the above to be a true and correct -
Registrar's record on file in tiie Bro:rard Count ~IealthyDef the Local -
y[[ Fort Laude~•dalE;, Florida. , y' partment at
,I~ ~f tr , : .
(Karp~,~a~s„•Not val>.d unless raised seal of the Broward County Iiealth .
:Dcpar~weat is affixed.) _ _ _ -
• y ~`z ` _ s. • i _ ~ . .,~!%./~~'~,?''~'„C,' .1 - R E C E 1 Y E D .
•i ; ~ Clti i1~ GROUP LiFE AND
t'~,i i ~'s~~v county llealth Officesand Local kegistrar o~~~Ri~irrow. t;
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Deputy Local HcgxGL-rar s
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