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• st.teotlFloEid. CERT1FlCATE OR DEATH -
-DapartnTent of Health and RehsDiKtsthe Services sTwTE~ ?E~s EEa
FLORIDA
VITAI. STATISTICS ~ RialaTnAa•s No- / ~v
OECEASEO-NAMt nn• rawt t• SfM OATS Oa pEATN • coca, a••, qu i
-vPE OR PRINT
~ A nes Adams ~Female•, Februar 2 1978
PEgMANENT
BLACK INK RACE •rMin, rasao. ..salt.. r..fuw, wGE-uar wta t .t • t . GATE d RMIN i•4rM, CCNINEII d DEATH
nc - ~ wc+• i «aw.• ~ •wt i rroa. Mn Mow{ rrr. •a•a r
~ f ~ ~ ~ ~ Feb 27 1901 ,.Volusia
1 l ATN w.fw uw tt¦rw Al CM tM Ma t.. teMn, a~w u.ea •s« .w.wa i
twcn ws a rro
Yes >r DeBar Manor
iTATE OE RIR1N ~ r ro• w ~.t w•rt Hi OE 1I111AT COIINERT MAlRR~D, NEYN MARRIED, fE'OUSE r r wt, «•t r?artw wrw •
cowtn i r tacrn r
utuu nse+tww E EE jaOw IL
~.wa atta•tet, N1MMft tlSIIAI CICCYPA ia•a sacs p .was sort aaarua roa• p ItR1D Oi.MJSflit OR M~OIRTRt
..aa r aua¦
ocCeaMa w r0aawa art. a•ea M attrao 1
yi^T~^°w•°M „ I~ wife I>• Own Home
.tyar.Kt «roat
•o•°ts~• RESIDENCE-STATE COUN1t CITt, iOMM, CIR lOtAIION rrana cii• iwMa i
Its. Itr Deltona w Yes w1639 Hastin s Drive
FATHER-NAME rise r~asit t•a• MOTHER-atAiDEN NAME rria• riMt! ua*
Shea ~ Katie Dower
IMORMANT.- MAING ALDRESS carter. a a.r.o. wo., ern oa •o.rr, p.w, srr
I/aRecords•David Lan Funeral H e 1212 Providence Blvd Deltona, Florida
PA2T 1. OEA11111tlAf CAUSED Rr. (EN?Et ONEY-ONE CAYSE rER lr+E EOt Nl A~ AND k1) ta+.aeM own •ria caw
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~-Frt n~ ~ Res ~~tt t`~r/'+~nn ~t i l~M• ~
rrrt«•q c•r?se r«, an q, oa •t • towa0aarita p:
af••rM~ tM YM~sa•
tnwo uosa uar
kl
PART OTMEt SIOtlrtICANE COtIDrt10Ni: torrniaa corwirwwo q sew art rro• alum q uaaa a..w « •.n i br AUTOK! • rEi .ryas nwNwu eo..•
'a ~ a Li 1 v 1 '1 (C ( ~ a ~ r •ta a rior p~iati atna.w.ra t.tiaa
« IIItD~TtRrrtlD i Mows. M•, nut Now INRJR/ OCCYRRED r twill M..w p iwraA rw ••at r eM ?•a M, Mar ra e
~ ~ M. 7R1
IMwT AT WORK MACE OE NJIRr •r wtirr, rear. s•ten, r•croar, IOCATIpt ~ sraetr p a.r.a. wo., an oa qoM, pct r
i iaa~r• nt p wpi tii•+0 itaG.,nC. tarace• i
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•.M ut• y,. car/iaN •rMe Ow r M/M rrDr vif:r MM oE/Uie OCCY~ •t sa h.at. ow M!
TION- rwrM Y• nu ' rornr Nr nub rows M• wr aoa• uM M•M. iMOwr f!7 w. •wA. q M atq
r .rnwaw rile ~ ~ 1 . ~ ~ ~ 'L - ~ % ~ 7 rE! n L . y(i p r. arowasoa, arw
na ata.wo raor TN Tlr r ' 7N. ~ J ( ~1 ri rl •o se c.wew a•wo.
ClsTi1CAT10M-MEDICAL E=AMlIER Ot CORONER: ow me tart a rw wow p a•M sa aectatwr ..r raor.ouncw ew
aa•rw•nor p Me sow .ioiw me i..•tsMa+•iow, « rer or.+aw, cowl. eM• n.a was
saes ooo.tata ow aw are w ase q iw uiwetai wna. ^ t„ M
CERTMIER-NAetE i•rre p rw•r eaeate Oa •iirt crows. e?•, •a•ar
Jerr M. Robinson M.D. a.. t - ~ i~.
MARNG ADDRESS-CERIRTER B v~ . Deltona F l or l a a 3 2 72`5
RUNAI, CIF/AATIOtt. REMONAI OR CREA{ATORr-NAMT LOCATION tm p aD:.w acre
~ aracr• r
B ial ,aBelleview Memorial Par Daytona Beach, Florida
DATE ir01/r,..•, •eM~ WNERAI NOME-NAA~ AND AODiESS ~ anea a t-r.o. w. ern a r .w, sun, • i
Fe 6 78 vid 1212 Providence Blvd. Deb ona, Florida 32725
vS. ~6T2 E ~ Ot - LURE erwta rye r ext:es
E
. CERTIFIED .COPY
I hereby certify the above to be a true and correct copy of the
Local Registrar's record .on file in the Volusia County Health
Department at Deland, Florida. j
1
(Warning: Not valid unless raised seal of the Volusia County
;Healtb•-Department is affixed.)
_
.
A ~ ' • {A~ County Health Officer ba Local Registrar
Date. .r. ~ ~ i -
. ~ F~ ~ Local Deputy Re r
- r
~ ~.n !1! ~ `7~
f~EO~CAf~i~ t~EC~• ~
- 9' RO~^ ~~NtT
- Ct.ERK C{ ~ -
d'7'7983