HomeMy WebLinkAbout2141 ' State costa ~ Health 4~~CERT~'ICATE OF DEATH arse lrne xa
Bureau of vital Statistic Y L O S I D A ~ N°~ f
L M.AA3 OY 1 ` ~ i UStTAL O! i~L'iA®
(a) Cb11Ci</ A.C.. tw~~ x (a) ~ .a.f~ i c ~ (b) CtomRtrQ ~ ;'s' - ~
~ cel pa~'eettwrlt ~smmbee) c x te) cits ~ j er
town x - ~ (d) tltreet - r" ~
cal xan. or hoepitel a ~ • ' • ' ~ ' Ito
lu not m haspttai er 1n.tttutloq, writs atnat nue4bsr or 1`
satlon) ptlatn of ~beetaos seimtgt a+s ee m
I.enstb eT ets,>r: In bosplta) oe . z: r.. name aonnN7
W At plans at '
l whether ~ean~ months ar d+ur.)
,i ~ ~ _
i~ « ~ ' u veteran. s (b) tloelal. IC;L ~iVICA'lIOx , ~ .
C 4 n.ms ~ ~J' l ! ~ x ~ !0. Date od Deafh: ~ . t)q
~.~v-
~ 4
~ q i 8s= ~l < i t7slor ar _ Ye.r_Tf B~ yrm~te ~e
~ c. ~ ~ ~ !1. I hereby adi4 tba! I attended the deceased from
d. t3leils. married, widowed or
oC ~ ll tal u widowed qr diroeos~. huebod a! toe) that I Lst saw h--. allt~a ~ : aed
~ a wds ~ f j ` l mot.! • , - r . th'~t d~eh oteurnd on the dais and hour stated shots. DtratJoa
A •b ~ d (b) A=e o! b ar wlta. 1f alM yeah ~mediats carets of des
I T. BUth date or dece '
OC ~ v (mot)th) (dal) (ear) '7~ ~
i Ase: Yearn llmlha +bys I! less than on. dq Dw to . ~ , . _ • - ,
Fi 1a ~ f ~ Y' min. Dus .
C tl. Blrlhplace Ofher eottdl
:p o (Girt, town oouny) . (State a toretps oountr7) ttnctuds pcedoanq wtthtn s months of Beath)
11. Industr7 or ~ •r. i . ~ • ` ~ t~ 1[aioe t1~t
aR opera IIaderl>is
'S . r ' r:
- / . tae u?me so
u- x ~ . .
~ ls. Bird, ~ L' ` ~ ~ tai.. data of operattan) e~har~sed
~ e l! 1falden * , of tistioatd.
a la. Birth ~ ° '
~ ;i. I!-death was dos to ezfaraal eaut~ tm m the toUowlna:
~ 10. Informant's sisna ' ~ ' ' ~ ~~(a)~tt~mbabb) waidank wtLdda bomidds (ttpeM~L
B 16 (a) ~ji _ ~ (b) Dats ot< oaw'r+mt~a
(c) Wheys d!d 1q~ta~ oM.=
17. Burial. cremation oe ` (db oe town) (Go~mb) (tltate)
17 (a) Data yl f ,Z-1T (b) PL ~ ' ~ , '-1 s (d) Did W~7 Doss In oe abed homer on lams. !n todu0rlal plaoR
i ; ~ " to pupyp piaosf
O. i xo.1 18. >fttneral DireMcr's 81~?a' . `:.1 • (~4' bpe ~ per)
u (a) A While at woc (~"Iteana od mi»~
~ • i ~ ? ~ ~ firer of p~•. ~ , t
s• i?. ~
1l1. itlled__.= ' ~ Local Re~lstrar ~ Address a)`•~~j-, ~ ~ • ..J n.~. sites-~~ IR. A
. nwwy ctTity ails to oe • trw and tiotrea Dopy of ttt~ troca~ 19$0 JA~~ I I Pik 4~ OS
Registrars record on file in tfie St. facie County Heehfi Dfip«t-
~ ment at Fc+~~ P=~:ce Flo•Ida. E(OJ~Ak0 FECOkl1f0
GER
POITRASA~ r
(Warnin;,. '•'ot ' .,mess raised seal of ftie St. ludo ~ RK CIRCUIT CO
t„ounty 7e_•,?tme?+r ~s affixed.) a
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t,.U•J ' _,~ttt~ ~)~t.:~r ~ ~ RlgNtfet F.-~ .f f _ ~ ~ ~~V
Duty Local Reols!r+~r ~ _'j~,1 r• i
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