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HomeMy WebLinkAbout0698 • `731'72 ~ - - - - CEkTIFICATE O!~ bEATf1 ORreTwRwT d lir~hlt t+ta Febti6tl4Rli.e GtYkeR tTATi rift NO...__~ n,tlvcAra=rrw,»I FLGRIDA I+PE O, RRINI IN o~wa•a•asrff.?t-a•/t•taa P[flOTR7Af,'~ NO ~tRMANENT INK DtCEASEO-NAME ~ ~'tti r.ttrl Ls. SEC OA71 Of UTAIM IrONIr. o.t .f.~'~~`~ - RACE 1•'a:fq• Ntsto..Ytr.C.M aNRUr, ACE -.all ovott • •t•~ .•••r•r f OAif Of Ury4 Ir~•+•r• r••, COUNTY MttM / tfC. t sqe''• 'a / ,,~~`pp tnenert n ttI rof ~ w.1 ~t\ rl.•. /y~~ ~ LEY, TU O[ EJCJ?)tON-O~ D:AIH Naaat uR •.ai ?1^;if1Al O~ O:Nftrrir17U110Ntiv• t No• N tl•Nlt, cwt f•t!t• a•fa .alt 1 n /-~%+-r+'7 s~it.7'yl~r'! ,t P•5 i~/~L?!?~~i`!sR'i7_ _f?&'7? C,rt?~ _/7'R__~_ SUTE Of NRTM t• Noa IN r e wart CIU2fN t~ Wt1A COVNIiY MAtuED. NEvER MAKIfD. - S'~RVwNC. StOIS[ 1....tf. ~I•t .YI 1. N.•,f 1 covNn• I d W~wy~AD. D'IYOKEp I.rtcr.l gyp'' Y aJ•1 naTf.e•Ia t ~Ii(/! ~p/'~.~_ f G.~ • J . 1_ii! L~'K li~~~~~'?)!• ~!/4r~1 r ~1 ~'.r% ...ar otce.sto SOCIAL SECV~77' tesaiiR ySU~I GKCV~w/10N Iowa awo o• ton o: ~t ouelNC coat a r1ND Gf RuSwFSS OR u:D./JS1aY - +•.SO rtaM - MC~••fA M p f+•p1t Dlr tN N tll.tt: mar/ ~•.T~•,,,•.o•., cM~, ~ S6 ~O ~ A - _ 1)~ l'~iT~ 1q~1'YI lA_ Y w or+ttaN RESNi[fN-C~E~-SEAf~` CEO-VN~ir Clay, lOwn/OR tOC:.11pN •~t+ot c+R ,IrNt S/fEEi ANO NV.•atEf~` L_~.~. iw /~/0/'//~~ Itr~~rOGtJ/Lfi C' ~t?r'A rN. cN~yl.J~ No' It.~a~~~ CY . s~L! . fAINEk-NAME p e• r+Wat - C]~•• late NOlM~R-NA•DEN NAME t•q• A YIeCVt /Arj Wf INFORM NT NAME AlAlwCi AGGRESS .eftfU Ot t.r a Nn , crt• pt Tpr.- UaT1 M; ' - 1)~~~f7 Y r /J1. ~1~'/'.-~~ /T9tfq,•~ 1)1 OG~ / .T'G{/. ?~~~r~iP.. ~•~i.~.C~Cz.~?~.~'rt_cr~t~~ ?A!7 1- OEA WAS CAL'SEO Rll: ENiff ONLY OhE U7SE ir+ lrtf FOR ol. !pl. ANC tr3 afI•"tr•rq ~ 1 1 { un•uN oNen .I.o r. IE trrtt/un Yst rrrlcr Gart flea t7 l(V~ /`-1~_iaC_\,~' J IrrfrT•It Cart! fOI, /11t p• W ?e . CONUfArtlKt eLUNp ta! VrDtt- t•Ir0 C•Yel laef IAtT O,IIE¦ SICsRttlK:ANT CONOI710N5: cONwrors eWteNMla.O p p[atr wf Nof telarrr IO eaust CI•iN IN t•t• • al AUTOfSe a YES vuf nl•su+f•s • tlf f.• a•Ca f S'UIO +w call. rlN.NO a- - ~ Of taarr jl.~leN'= 11CCfDEitT-S/fitW( OOO~~~~[)A~~YJ I roNtr, oa.• n•a t NOllk MOW IWURY OCCURRED t eNnt+ N.\fYtt w TNtYa• .N r.tf 1 pt rat• N, efr It I I.~/d OR IfrDE7tU1tINlO 1. ~ - 1'SOopc I .!4 lh M 1)M iiv1,YY A7 YtL~ .L:tr ~~!_K'f C~? '41utY of Yor. •••r, t•Nn, t•e,o.., IOCAiION I tntet oa t.. o. No.. eln of torN, stare f tera•• ne of Not (ofr+n tae; ,ex et•ee•n. i 70t I~r L~ CICIfKAI.ON- ao1Rr s•• nat I roNnl o•• ft•t I .NO a.f• y.Y Y•w Ntt ?u+e c•. 1 eon •u.1 VrtM ..alMw:w tfee+•uto r.t .,.cr. n. - RnYSKuN- 70 J r0«*r- Oa• •t.._ t00• aRl Irrq.rtl r^~~t..•r D, •o •-f ' a aRtNOfO tut ~t ` -1 pl rt f.+Or•'.1'•.• )It orcf.stC._Mr J )I l )It ~ J ilf ~)ir~ N to Ml c•YNH: V. f.ER)I(K/111ON-taE pt~AE IAAMINtR (~R COROt+Ef' riN Irl t•a f71 »4 j u0'It W Of •TN tuf Ot;fOa NT .at ?t0••AlNtro oeao _ t.•rw.r.•?•• d rlr tOC• •NCf O. fuf wr•eT ~•Tlbl, .N Nf (•rl•N ~v, rOMN Oa• •1•t wu• t ttaru X(V••ID Ow INf i•n aN: OW •O •+r c.YUls+ sT.ne _ _ ~ M m laaIFIH- r ANl TTr•t of i~•wn ^ as K',~wtU ~ e }.I a ~e~ (>-~I~~IE IC;v(p ~.1-~.'~•j~~•-.~... fit. ~ -Z.-.<t S__1 L^.1~_t •~1 ~_1''! ~ - !~~r -•"le~~_f)~' _~-"1T l.U l?haG AI`~RE!S--t R':IF :Ii ! ~n:f• r• t r f~ .ri r~ Oi T(,F'_ ~ :~ITtI ~ t,• ~ ' ELRiAI, Ci Jal10N• Tc MC1JAl CfMfiER\ pC CAf RtA70Ri- Ntal• f+-~6 [OCA710N C•^ GI eO~r f••h /,r t = ~ DAt. •rG.•T C••~ l 1t IVN.,•1 4C) -NAa•r A" :-i Tiff P No :'N 1 ~ ~ Lf"• ~/i lr~l~*,(,~(~ i~~T~~t~ _~._~/J f ~~/~i~y_=i'r`k F!'rr~ ,ir4 ;'itP i%~-!~r~i~7.~Ca.'~~ /=".',f- v. 5• s617 fuNEaAt Ur,S/f?OR . y~•lwrre[7) ~ ~ ?fGISfQA+_ _r .Ar:r( w't sreu:io s. •O:.e Ir .r•t.I ~ . Rev. 1910 :S?~-%~ ~ij•;~.1=....L..:..~.~._{ a-: ~ r1.l.e? L: ~ t_?...a / 1'i:.~. a r,FRrl Fr l:n cor~v . i illereby>~certify the above to lie a true and correct. copy of Lile i•o~al nPKish-arts _ record pre fi-1E ~.q the Brouard County Health Department at Fort Lauderdale, Florida. r (WarnidgrNdE;-vs~~id unless raised seal of tl,e Bro •ard Cc1 ntv t aith Pc' t. is affixed.) • Crnlnty flea] th 0 f i cer and Local Kegi stra: i 2-18-80 Chief eputy local Re~i trar 1980 i~AR 12 11R ~ 38 Fr~EO •we Accorto~u - SLLUttE Cp~gTY.fU. l10fiER POITRAS • CLERK CtRCtHT CGUI~T / RECCRn~'fRtF,EC~-t3 / 4'7~1'72 eC~K327 p~cE 697