HomeMy WebLinkAbout2642 4'7t18f31 9 y
~~,1~ 3e~,e~ (~~~~l~r.y t-~ea~th '~enartment
state of Florida CERTII'ICATE OF DEATH
Department o[ Ilealth and Rehabilitative Services F L O A I D A **ATE: Erlt.e No. -
Vi7'A1, S•TATIS'1'ICS REGIt:TRAR'S NO
TYPE OR PRINT DECEASED-NAME Ir• r+ee+r +•ff SEi GATE O/ pEATN ~ «o«I«, e•r, .e•f l _ •
IN . EUGENE N. BASCOM :MALE , FEBRUARY 1
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WHITE _~71 w w f JULY 24, 1905 PALM BEACH
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~ LAKE WORTH ,1 NO DOCTORS HOSPITAL OF LAKE WORTH, INC.
STALE d RIR1N nr uo/ e. r f • . «•rf ClfllEN d WNAi COUN1lr rauenED, NErE~ MARRIED. SURNIrRdC SrOUSE
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I..If r Of•M SOCIAL SECIJirtr NUMBER VSUAI OCCVt'A1gN +wA ae+e Or +rofa coot fNlfwa toff p- KRNp d RUSRaESS OR INOUSTRr
OCCUfMe ur .rafaura lrf, AfM grlfro /
..afll+uf+ou, arv~ „ 343-07-7498 GROCERYMAN GROCERY BUSINESS
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•or+ffl0« itESM)ENCE-SLATE COVNIY CRr, TOWN. OR LOCAtION 1«fro1 cll. f•nf Si~[Ei ANO NUMREE
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/ATMER-NAME rlfA r+eetl f•ff MOTHER-MAbEN NAME nn. rNblf off
„ S1LAS CONWAY BASCOM ELIZA JANE LAMPLEY
- 1NgRMANt-NAME MAR.R+fG ADDRESS Ifufn of f r • r/o , cr• of fo..+, sun, frl
MRS. NOVALLA BASCOM It? 1370 SO. MILITARY TRAIL WEST PALM BEACH FLA.
DEAN WAS CAUSED Rr: DENTE ONE? Orf[ CAUSE /ER tME /d (eJ, 161. AND k11 fffrffr prfff •/re M•f
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~ ~ores~~~lill Blvd. IrJest Pa1mfE3each Fla. fr
~~fS[ ~ BURIAL, ClEMAt1ON, REMOvAI CEMETERr OR CRE•MtORr-NAME IOCAtIOff cln p qr.. fun
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Tff REMOVAL iff PLEASANT VALLEY CEMETERY :f+ COLLIN_SVILLE, ALABAMA
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DATE rrpltw, f.., aul tUNERAI HOME-NAM( •?ap ADOE[SS I smu of f r e uo • clr• of /o.u f••n, rn+
~ ,f. FEB. 5, 1977_ DORSEY FUNERAL HOME 3525 S CONGRESS AVE. LAKE WORTH FLA.
V.S- #612 / IRfCT ifU R[CdSIRAe/ ArUf[ own etcflvfo R• IOC.f acisn•e
Rw. 7/76 i„ Ty ~ 1ti!_ ' J ./~•i~i._ ty - G c• ~ 7
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I HEREBY CERTI,~•r-;5:9$0 ~ `A TRUE AND CORRECT COPY OF THE REGISTRAR'S RECORD ,
ON FILE IN THI$~F~I~B •~r',,~..
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(Not valid.tt~t~ess the a ~r;Palm Beach County Health Department is affixed)
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I ~ February 9, t C.L. Brumback, M.D.
--Z. ~ ~ R =~-T~~,. - ~4'7(~8~31 Local Registrar
Bureau of Vital Statistics
West Palm Beach, Florida
l
1919 DEC 28 ~I1=48
FILED ANC PECORUI U
S
RpGER
pO,TRASA
CLERK CIRCUIT CpURt
VERIFIES-.------~
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