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t ,
f ~ 'CERTIFIED COPY ~
WE ^..~e~. -THE COPY REPRODUCED BELOW TO BE A TRUE AND CORRECT
CO-, RECORD ON FILE IN THE BUREAU OF VITAL STATISTICS OF THE
ST F ' EPARTMENT OF HEALTH AND REHABILITATIVE SERVICES, DIVISION
OF- - T ~ e MLLE. FLORIDA.
1 Q:, _ OI THE STATE OF FLORIDA. DEPARTMENT OF HEALTH AND REHABILITATIVE
1! AF/IXEO.1
t -
• ~ +Y _
~ 4 '1/. ~a°'~ Vim-
l• 'DEC 2 71973 CHIE/. fUREAY OF VITAL fTA71iTIC!
. t• hT
_ y yy~
STAY[ tl[GIfT1tAR: OIR[CTOp. OIYIt10N VF _
M[ALTM O[rARTMENT OF HEALTH ANO
+
RENAt1UTATIVE f[RVIG[t
F:- - i
RATE noway o~ilKrtilrn CERTIFICATE OF DEATH 2,~°t)'~' ~ •
nUREAt! OF 11/TAL-STAT1lT1Ce STATt FILL NO.
FL08IDA
BIRTH NO. REGI6FRAR•8 NO.
1 /tAtt OF OfATM G E NO. L YfYAL R3Et10EMC[ f Nv~ taeaatat taaa. wohtw: R~raeaa aa/a.a a~uae.aa;
t CtlalNTY e- STAY 6. NTY '
toward ~ -~3 Florida froward
~ CR1/. TOOM. OR I.OCATtOM t. K MACE Oi DEATH e. CITY, TOOK. OR LACATIDN e. IS RESIDENCE
- :~ISIDE CITY LIYIT57 INSIDE CITY v 'q
POID O Beach YES® No? YES(3 he~~
L RAPE of (ljalat b pea~i0et• tRet ! LENGTH OF STRE ADDRESS
ON A FARM•
B 1 d • ~AY IN 16 TES ? hC '
Z RiR~ OF Fiat N11~s Lett 1. PATE Xewtl Dq tie?
f+EC[AfEO Of
(?ti/s tr /t'ttt) DEATH
S. S[x w 6 COLOR OR RACE 7 MARRED ~ NEVER MARRIED C ! DATE of aRTH 9. AGE (tt /tata uhoE~ I TEAR LRIOER 2a +,ec
tat[ bhtile/) Neat4 Qua Ratty ~ .fl.a.
OIDOOED ? DIVORCED
IOt_ ~
~
yw~
~ ~ V ~ [IRD OF RuS11E5SOR 1R011STRY 11. RWTWIACE etr a J!r!i/n totRtr/) t2. araEM aF.w?T mRtraT f
ti /ATMER"S MAYE 1L •MOTIIER'S Y RILYE
Zrtie~ 1 a
IS. SAS EVER w U. s AREED R~Sa K. SOCIAL SECURITY N0. 17. f f{OMA •
ITa r. e. a~laae~l u/r.daar~Ye dawar!
~ ~n awn Aalbeaa
Il CMRi[ 0/ OIIATM (Sa1n ett~ tas tilt flt te), (6). eAIQ (c).I ~ ` INTERVAL RETrEEN
r] ass Alo euTN
rART L OEATR trAS CAUSED !Y-
W MEDIATE CAUSE (y
GltfitMa, ifetf. Dt1E To p)
eDar c~~tt (s~ I ~ /
atet~F ~ DUE TO (e}
_ !/fRr tpx teat.
G rART N. Otli71 SIGIi1CAllT OOaYataN6 CO1t10LRi1G TO DTA771 tAJT NDi RELATED 7p THE iIR11t>WL OLSE/ISE COtmITtlN GRRN W TART i(e) TIAS AUTO?SY
j. rERFORMEC~
YES ? ND
1` 20t. lG6. OESOi:RE /IOIa RUURY OCCURRED. (t;ettt tatwt yea)tt/ tt Pere t of Part 11 y ittw ifJ i
f' ACCIOEaR SUICIDE IIDatIC~ Td
v D D D
~ 2at TlatE OF Nett 3~(etti, Del. Itar
V tR1URY _ e. ae. .
i Q R s.
r
I ~ RIIURY OCCURRED 2tk. RLACE OF IMJRY !t. ill a el.Ott AotRt. 2Df. CRY. TOOM_ OR LOCATIDN COUNTY STATE
¦IaEE AT ~ MOT ft11RF ~ ~w• I~orl. aped, e~rt bfp., dr.l
~OR1C AT OORK
21. !attended the deceeeed boat ~ nd Lrt yew elite on ~ ~ _
1)wth oaxurreaf et at on the date at et?ore; end to the beet of m)r AnowledEe. lr the uuaea ateter:
?Ia- t1IOR1ITURE (!Af/?tt ar tYtt~~ 226 ADDRESS 22t. DATf S+GhCO
ytii l~ ~~/Y~E~,x~ ~tlyE•~lcwsee,~ ~ 7~28~yit
73e RUR'Jlt_ taE11A1T01~ Zb. DATE 1 23r NAME GF CEVETERY OR CREMATORY 23Q LOCATgh JCM/. taa a. or rount/) tSYarl
REtapeAt (Spra//1
1 B a ~ a
2~- OR "S TU A,Y~RESS 2S DATER D. R LOCAL REG 26. RfGCS:RAR 5 SIG TORE
a o Beach+ r~ s
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'~~R912U
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~ 19~ JUH. I 0 AE! 4 4
fIIEO (~(~ItC RECUAi1tD
STS
t~iER PO
TRAS~-
CLERK CIRC~~Tn
RECOR• VERIilCO
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