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?OLK COUNTY HEALTH DEPARTMENT
Wlllisa F. Mill, Jr., M. D.(Director) •
CERTIFICATE OF DEATF, ~ ~ ~ 16
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••~r~~r ~rra~~y cne aDOVe to De a true and correct copy of the Local Registrar's record
~ file in the office of the DIVISION OF VITAL STATISTICS, at the POLK COUNTY HEA T
cPARTMENTt WINTER NAYEN, FLORIDA.
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County, fi _ 0 r miff local Registrar
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i ~ L ISSUED • a/Yw*•w_r lal~.J.' .
33 CHIEF DEPUTY R ~'R~"~
•+RNING:, NOT VALID UNLESS RI~•s~,,S~_~~~~ DIVISION OF VITAL STATISTICS, POLK
COUNTY HEALTH DEPARI~T ! ir~l
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N{ ~3~?'~J~3b uoX 109 Lake wales, Florida 33853
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