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OOIkTIY IIiAT~N RIVBR
ComeB tWaT EI.AINB R. BBRMABI residing 8t
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Coral Springs, Brevard County, Florida ~ gyp, aft •
being duly swops, upon oath. deaoses and says:-. -
_ - 1. Zhat I was meiocried• to ALBxtt'r- s8x~x ~ _
Gtl .the 13th day Of September, 19 76~, at Fort Lauderdale, Florida .
_ 2. mat. I lived with the deceased as tusband and wife con ~ lly
- - firom the date of otnc memcLage up to the date of .death of the decedent
D[i the 9th ~ d8y? of - Septeml.+er , 19 77 -
~3. R~ 3. Shat a copy of the dpi erste of tt~e deoeder~t is attad~ed
hereto and made a part hereof .
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rman
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,;and subscribed before me this 10th ~y pf January ~ 1980
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~ , _ I~btaxy C, State o at
- - : • - Mq Co~missiatl E~ires : ~i/~/F~
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