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HomeMy WebLinkAbout2908 • , 4b'7244 ~i:rl/• c r MloNlt., E TI I 'I DEATH ~r C R CATE Off' 1+arlntcnl 77f Il, ,lth a!ul Rchal•7Jil:+lifc S7•~f•iccs STATC FILE No ' ~'rr.~ 1. s•rA•rlsrll.s FLORIDA , REGIEiTR AR 5 NO . + + (fl. r-~. •1'~ E DEClA;tD „AM( r•osu uf+ Stt OAtI Of DFa7H . rr•.•". o•...uf • 1V r\nnettt~ Putnam Clonl<~nt ~ fernal~ , Al:~rch 7, 19713 ~E IIt.7ANEN? _ f _ Hl .l (:K 1.11: RACI .•..•r ..r rn¢•r I.(.t -uu v+ora ~ .emu ju•mu r e•• CAIt Ot R7RrH •.o«.r o•r, COVNIr OI DE ArN ra f fV o f•af• rOf o•• 'lJlt>.t/• ( "'~b• ' i ~fi 1] 1907 Isroward [ ` ~ Cnr, tpw~f. Oo tOCAtICAa Oi ~ jii., •*.frof un .w•n rrOSt•Ilwt OR O7HER INStItU7~ON-- Naw[ ..r ..Or r•r.f.. c•.f f.nf. •w .•v..ua • r• ~ frfer• •If W ro Plan' ~ltion yes rd Plantation General Hospital Sf~~t Ot 71Rp: ro• .r v f . ~..rtClif2EN C~ w?Lu?t - r COw+IRr MAtR1ED: NEvtR MARnE6.-- ;SURwVN(; SgUSt -•n. cif r.wf.• ...w New York U.S.A. IWwo`~f~i°N'4f~d°""`"" ~ John I. Clement • oe••r SOCK?t SEC'!f•ir NU~fR[R uSUM CKCU?A71pp~ +c•.f awo o• .o.f twrf ona re roar of TxwD Of WSWESS OR INDUSter ,Q75_-rJ5-5635 ?~etirec~ ~is~rict Manager I~~~ Avon • R[SIOENCE -S•~'E - CO~!v'v CITY, tOWN, OR lCKA710N +~f-oi c•n i..•~~f Sn(Et ?NO Nu~+Rf~ r f•1 r• •lf Of r0 • Flori•la Br:lxard Pompano Beach Sio Rt.2, Box 822, l.ot C-1• IJa 116 ,k rb ~ ,<t /AINER-NAM( IIUr r•Op/f 1•ft M()TNEf-M1r0(N NAME r+fft r•Ogf ufr Fay Putnam Belte Hotchkiss ,S ,6 INtORMANI- NAMt HARING ADDRESS If•Nfr O• . f O r0. tin O• rOrr• fbr,. to. Mr. John 1. ':lement ,;6Rt.2, Box 822, Lot C-14; Pompano Beach, Florida •Ap 1 ..Hour. w u•• - pEA7H WAS CAUStU RT. (ENTER ONIt QNf CAUSE ~f! (IHE t()r tpj, (b). 4N0 Erj _ _ alfrNN OMffl .rfl b 10 WW'C~•1 (Tuff Ie1 , h ~ ~ it ~ ~ f 6rrE . f • sr /ref 1 ^ ~ ~ 1r , . cOrO./+0 rf. •r •r• ~ t ~ I + , ' - ' VI ~ , 'G rrKr c•.f uff fo J 161 h I ~ ~ ~ ,h r.rfowf cuff +o,. I o~: •e. o.:i . co«uow•.ce o• ff•nrc frf vroff- f••rc c•esf f.n If, - rARt p QTHER SKirV1i1CANT C•J`r7!t10• ea.o•••o f eofnufvu..r ,o of•rn evr of u.arfo roe uff ~•~r./.w •.a . o• `AUIOISY et YES reff ure~ref _ Cr/ ` f. .ff Oa r0. fiDHfO •r QerHr.r,ro r• '7 ,'t nQ O. Of•,w J \ ~ - ~ ~ '9r ,r9D Ir-iMb~ 1 ~CC'OEvt, Sl;rCiC: OR OAt[ ~'E iN r' ~ ~ roaTM, o•r~r .f r HOUR MOW INIUt'/ OC URREO r /r'f. '••rvn o• .••wa• ••.r r of r•er u, ttf..a • f+OMK+a[; OR •^:•+E7ERMIWEO t50•c•ffl IN)Utr wi w%•.ari ?lwCi C~ nuUra ~ rect. ••?r, snur, rK,p., IOCAiION . fntt• of . r e ro . c+•• m ro+». f••q + fleern of O. •+o • on K• . r r': n(•n ~ - ~ • •n. - 1C+ 2+57 / ' j~t GE RtIf iC A71ON--- .•7+,r o•• •f•a , rorrr e•f rua •ro f•fr u.r r•.. era ...e o owlo•o ro• rrf 0[wer OGCUUlO o .rf •uCf, o.. - rff~SKUr• O ro•.,r o u aoot •r+n of •rr. .ovu o•n. •ro, ro r.r • •n1 rO1D '••r 7 ~ ~ _ l :0 7 ~ o. rr a•.Or NOG! i• f Of tl•f1D rlOr / / ~ / / ?2'6 7 Q 2,( - 2:Q ~7e r0 rw C.ufl+i. fl• { CERtuKwipN-MEDK~I Ex~i+~!fia C? COaONER o« rw f•fn Or rrf rout or a•w rrn o fare, .f n fo of.o ff•rw.,p.a o. ~w f»c• wD~of ....re•-.. •c,. ,r orw.0«, rOr!n! -f.¦ rOUf rf ••r occunm c. °•rf e•rf ...c •c •"r r..nni+ s•••fo ~ t 7a M ?2O ~ _ CERi7E+ER-?lANf r...;.. , - - - SK:NAtURf / _ o~+fi e ,n,e AtE S~GNE . . •u. j Ur Donald J. I'levv ~i.h. 2J6 % i• .~C ~~x { MAILING ACDRESi - CE~fprtl Fall• Of . r o r0 ~ nr. o. ,O~ L•q r•. 4IU1 South Hcis•l:.tal Drive lantati6n or'd . ~ - ltUR7Al CRE•Mt•ON, iEMQVAI CEMIIEi• OR CREMATORY-NAME IOCA SON em q rprw fuq ' ~:'-a.F721 7:r~rlat irln ~ Kr ~1•~r Cal-Crematory 2.( Pn?n!)an~ iSeaoh, Florida (lAl _ - •f•• 1._~Nr R/.! •/(?M~-NAMt AND SS - irff G a. 4 v G ro.-r, fr•r1. f.r .~r~tar.~', ~Y7?•1~•' `~,R. ':ly Kraoer:~f~ East ~ii~lsbur~• B~.vd; llc(~rFiell; Beacit, Floridc~ 1 ~UN(iwt = ~ v c. ;N.?URt REW A A r „ o.n x[:eweo Rr foe ~ ree+snu - CERTi Ff i;l) • COPT' ''7"'~~ ~ y certify the above to be a true and correct copy ~f the Local Rel;istrar's ~ '•;f~recot'~;~on [ile in the 13ro.~•arrl County Ilealth Uepartmcnt at Fort LauderJale, Florida. ,r ~ ~•i (4:ar.E4~g-Noe valid unless raised seal of the Bro~•ard Cf~+nty I alth 1'e t. is affixed.) 1y`~• - - 4'7244 ~ , ,I .3~0-78 t ¢ ` t; 2l County health0 titer and Local Registrar k , ~ ~J~ f i.. - - s ~.IGGZ~ z CLE~:`.C(^~'.:(Tt ~~t Chief eputy Local. ReRi trar 5 _ ~7 i,R 320 P~~r 2904 - 3'J7K