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!•Ir. Georr;e Green 402 North 56th Ave . , Hollywood, Florida 33021 t.
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- CERTII tEe--NAME Len or own .
StGr,AtUEE i eE~.nt p not GATES p 1 rN.
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Alan L. Rose M.D. „ -:C... i~o ~u,,,~~- L~1 ~ r
MARRIG AL>aESS-CHIMKI ?ran :.o (rn o....-- .
?_450 Hollyxoo°~ $oulevard Hollywood Florida 3320 '
wttwl, CEEMw11pN. UEMOvwE fJAETEtall C1f C~EMAt();Y-NAME IOCAt10N c.n w toww fr•n f
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,f. Entombment _ _ _ _ _ Hollywood -Memorial Gdns . T.1 Hollywood _ _ Florida_
T)AIE INorr»- Do, rlN1 IUNEeAI NAME-NAME ANO A001ESS • fuN1 0. r. a r0 . c-i. w ro.». it•n. u..
~ti,, !'1aY 2r 1977 _ iiintter Kirb Cha el, 5900 Johnson St. , Hollywood, Fla. 3 021 ;
^~1 V.S. 3'rG12 rUNEe~I paE -S/tt;N•r , REG,St~At- IutE o•t[ acv~to (oc•, nentue
Rev. 7/7Ei ,A ~lT. Cl A.,.c ,.(.r SUb-Y'C rl^ ,w '1.
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I hereby certi~f~}tg';pbov~.~a.,be a true and. correct copy of the Local Registrar's
record on fil!-~~q~'et~;e.•~r~ira>rd-,bounty Health Department at Fort Lauderdale, Florida.
(Warning-No~',Val~~'dnle~Ab•raip-ed. seal of the Bro~ard County Health Dept. is affixed.) .
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~9~ aPQ ~7 ~ ~ County liealth Offi~ rand Local Registrar
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RLO~GLR P ITftl?s 433359
{LEN(C IT C6URI Deputy Lo al Registrar
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