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484356
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e: ~ • s ~ ~ iu~ilc~u ooi v!~ a CERTIFICATE OR DEATH RAtt ?It.[ No. _ _ -
~.A.? r.•. FLORID1l
•rd •A•r !II TN NA pIO1NTpAw~9 NO
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•.stul.. COUNTY ~ • ST T ~ CGbrtr
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B~ wy.. ~~orids~ droward ,
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" p•r- CITY, IOMM.OR IOCATK,N t. q •LACT W MATH ` r. ftTr, TO1rM,p11 lOt?TKNI r I; •fS~MwCt
INSID[ CITY UYITP ~w'••O[ UTr UNIfSI
""'"t - I~o~l wood Y[sp No® Hollywood r[s No~_ ~
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NAYt Od+ {IJwN Iw MtpY•+, /irt that •Ihr 1 STRT[1 AODRf SS
} ~ 1NONstitu`al°"i Irr`I1. S•w. A~~~ S+• 6546 S. W. 22nd _St.
} MAf1R[ 01 fktf All/ta+t L•N 1 DATE ~ f1 AI/ Y,:ra~
ft[C[Afl[f/
- tr?fN«r+•+! James Francis Lan ~"T" ~9 b~
S[K L COLOR OR MACE T YARRI[O ®N[Y[R YARRKO PATE O/ f11RTN 1 A6[ f w /r.?t <t uotw 1 TW tlrOtA to Ntl.
fntt lhtlf./1 Af•wLL• D.M Nw.r Ni¦.
• 1 t . Male White wlflowco avollc[D Jul ld lyll SS
p 1 a t n I / 10. USWI OCCWATKNI ICirr t.¦/ywM! IAwt 1OO KDIOO/ f1uSINESSOR NN,USMY 11 .IR1MHtAC[ (•STNt a Mrrlp twwhi! CItUlJI O/ ¦MAT OOlRI1RY1
• t t A p • r - brig w•tt N rwli¦[ hp, rrrw iJ rttftrll
.•"•nt Pa master Laundr 8rookl n N. Y. U. S. A. ~y
a 1 A e t ! n! 1}. /ATN[N s MAY[ • ( ft1OTN[R'S YAM1[N NAY[
t,...rlt.fr Unobtainable ~ Unobtainable
1 . SOCIAL sECUllnr Non [[[IO[eR,^ ft .lo[aTU!!f[ Af+fi.ra f, 546 S . W . 22nd S t .
116-12-066 1Qr ~ Noll wood Florida
7 u". r.l 11. CAW[ t•/ KATN its~frr •wt/ •we cptr ptr tlRt /r {•1, [tl . /rl.) ~ IwT[RVftl ftETw[[N
~ t r . e t e r CART 1. D[ATN wA5 CAIfS[O 1Y- q r ONSET ANp OEATN •
. t f ! 1 • IYN[DfATE CAU/[ (ta AGV {.w~ N• T.,,~~ J r'~• tiCNfw/
tn• e.r- t
t1fleAt• E'i¦IN4wt.+~.... G.y.~?M. A,.Tt•.,Os.f~-..OS.s
• f t" lA• IrAuA /at tl b 011E TO l?1 -
f e t . ! A •Ortr nru 7.1. -r
r•R?.trar . If•tfr/ fAr rwlrr• OtiE TO lrl_-
• t e n l r•. 72 a f/iq arfx trot. - - - - - - - - - - - - - -
~ o u r . • f - O /ART It OTN[R SNiiRrICART CONDITION! COMTRIftRIwL N) OUTN 6yh NOT RIIAI[0 TO TIT[ T[RNMff1l aftAlE CONOINOR fjIrEN W1 ?YT 1(•) . wAi AUTOPSY
P[R/OIINtO
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e r L • f e r • ~ ~ t pE~yE NOM INlUIIY OCCURRED (ERfer w•fr?t • h r/ tw Pat f a Pat tl y (frw f1.1
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t< 7 r ACCIDENT wK1OE NOYK10[
e1.po•t- r~ ~ ~ 0 ,
tton et - - - -
20t TINE O/ t4rr N•wfA, D•/. }e•r
?odT• ~ INluRr w.
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i 2Ol INpiRY OCCURRED ZOt. ?LACE Of DI1uRr (r. it r t~+•rf Ae'wr. 2D/ CITY, TONM. OR LOCATION CMJwTr STATE
a wNILE AT ~ NOT wNKE ~ pr•T• ttta/, N?td, yftt 0111., tft.)
1G ~ ~ WORK AT MIORK
~ ~ 21 / ~
f~~d tAt+ d.e•w.•d /?O,fr _ . to - •nd lssf taw h
T w/..e on Z
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~1 DufA txcu?rnd rE 1? ~ f ~ _~m on Eh. daf. aaFid t+bo?e; .nd fo tM 6sf o/ mr Ano+bd/•. /tom fAe uulef Hwt.d
tl] ttewA j2. t10MATYR[
a r • t o D• 1 ll rtr a Iklr// 220 Af>DRESS ?2t. D?TE SIGwEO
r o . p ? . t • A /f ~t--•tiG~f(i>,? ~+~1~ 17 - /H~• ~~r+•t 7-~.-~il ~ 9 roc L
e a 2J. ftur+tt. CII[rATtOr. 2}D PATE tTr RANE Of C[NET[Rr OR CREYATO#Y 23d IOCATKNI {t'•I/, f•rw. «t•rwf/1 I ~fMrl
ur -l.rftnl J 1 1 1967 Holl wood Memo Gardens Holl wood Florida
9 . ~ 612 j [ gREC;OR SN; ADDRESS e0y d [ S PATE RECD f1Y LOCAL rR~EG KT R S SWr TURF .,y
Al T. [/DD t Hollywood. ~V[Q~ t,2~, /7G - ~ t~t~ ~i.,~~L.~.C/i
. ~ cFR•rl FI r•.a rnltY
I hereby cer~'L~jt ` i,e~`ebo3e to be a true and correct copy of tl?e Local Registrar's
record on f~~e ~~i!-~i1e~~Broward. County health Uepartment at Fort Lauderdale) Florida. -
(Warning-Not~~li-~ ~riless t~ais~d seal of tl a Bro yard Co my 1 alth Ue t. is affixed.)
. _ 4
~z,•, - County Health O ficer and Local Registrar
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r ~1~Ciy~~i ~ ,
• }
4-14-80 Chief eputy local Regi trar
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484356
1960 APP 24 ~1= 56
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