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X90451
49i?451 1980 JUN 20 PN 2 1
fi [yO~ANO
N~EC~OABE~
~~p6ER E'O~TRASA.
CtRCU1T COURj
Hillsborough County health Department
1105 E, John r. Kennedy Boulevard
,lahn S. Neill, M.D.,M.P.H. p.0. Bux 1731 Plant City
I) ii~E~etor Tamp1, Flo2•ida 33601 County Office Bldg.
6TATE 80ARD of HFJ?LTK w CEf2 ! FICA
! OF gEA71-~
` _ OI)pEAU OF •YITAE. tTTAT16T1C0 FLORIDA ~AT6 FILE NO.
81RTH NO. REGISTRAR•5 ,to. 04661
1. !•lAC[ Oi pIATH COOS NO. 2. USUAL R[Sl0[t7C[ (R'Ar.r frr.arrJ h.r1 t!.,.hw...• Rw./r+n Mr+, .lwr,..)
COUNTY Hillsborough 39-062 ~ STATE Florida COO"TY Hillsborough
• 1. tlri, TOwN. oq EOCATION t. K KAG[ Oi DEATH e. CITY, TOWN, OR LOCATION f. 4 RESIDENCE
i!acDill Air Force Base CITY UMtTSt INaos CITY U/+lry/
YES CX N(i O Tama rES ND O _
1. NAME Of (I/ NM iw lwpitd, /iu ,trtrt allrt,r/ I. STREET ADDRESS
NOS/ITAL OR
~TIT~Tb''' USAF HOSPITi1L 5502_ Fussell St_ _ _
HAN[ os il-rJt Altllfe last ~ 1 OATE~ Afollrfi /w/ ) ar
iii«piAl) Anthonie Jacobus Goudemord ~ D~TN December _27 1968
S. SEI( E CO:OR OR RACE 7 NARR:fD }~l NEYER MA71AR0" DATE Of }IRTH --~9. AiE (_At yrRr! •T V`ttq i TEAq I:~OCd :t NiS.
. Male White wIDDWtc~7 aYCec[o~ June 16, 1942 -~`~6
tl)1. USUAL OCCUPATION ~Cvr Aiw/ 0/ra+l IeAI 10~. KIMD OT tU51AESS Oa INOUSIRI 11. i~glNP~ACE (.Sldr N (srri/w cttRlr[) {Z. t1Tf2EM Oi .fM11 r.'IWrTA?r
~""~a
j
or Nr"~ r'/`' n`w i/ "E"`n Army-Retired _ ~ Holland USA
k 11. YATHER"S NAME ~ ~ II. IWTNCR'S NAIDtN MME
~r :ilhelr.: C~uclrr~ ,d _ _ .':ilhrliriina Jaj%obus
16 SOtuL SECURITY ?r0 1)_ INTOAMANT c tIGNATUR[ Allrat USSe
215-38-781b Mary E Goudemond' Tanpa, Fla
It CAVi[ O/ DEATH (t:Ala a"lq e"r cant prr llRt /hr (tl. (A1. •AI (r?.) INTEAJAI iETA~[EN
/AqT 1. DEATN WAS CAUSED 6Y~ ONSET AAL DEATN
~ INMEOUTE CAUSE (a) CO
1~°e~tv_e:hear~f~l~lre _
C.edilioR,.:/.A/, :o (b) ~ Arteriosclerotic heart disease
trlid ~Ne ri b -
1 a9~rr n~,t (i).
r a1rJlR/ Ut rNlrr. OI.E TO {t) _
~ O ?ART 11, OTNEII SJGAIfKANT CQ`4'MTIp\S COATR111/TCIG TC tKATN fl:fl NpT fEUTE6 i0 TNL TERIIINAI D:SiASE ECNDITgN GIYEN LY /MT 1(a) 1'~M~AS AUTC~Y
?iRfOPMiD!
Chronic lung disaase; Diabetes rellitus _ _ YESQ~ ,.00
• ~ - - -
r T 20a. I~~SV) 2Gll DESCRIIIE NOW IhJUAY OCCURRLG ;)::R(rr :rdrrr a/igjurT ie Par! I N Pcrf a/i!nw la-)
~ - ACCIDENt SUICIDE HOMICIDE
V ? ? ?
~ -I 20r 7111E OF lloNr Aforltt,, 1/01. )'tar - -
~ INJURY s..
G P- ¦I-
I ~ _ -
w
~ 2Gd. INJUAY OCCVRR[O 20t KACf O: Ir:JURY tt. is N abort ApRIt, 2% CITY. TOWN. OR LOCATIpN COUNTY STATE
~ WHILE A7 ~ NOT WNIiE ~ krat, factNY. tUttt, c;Ji![ 6(.J., tft.)
WORK AT MORK -
E 21 /a(tcndtdtha6sceuedfrom?.Q~.~J.~~'l.:C3--.-, Io D:3C:27 ~.CjV3 -end/a,f a+M Arm •liraon~~sr_!_~~_1`_~~
Deatlf oceotted at ~~S m on tAa dat• atAted aDare; and ro the bear o! mJ. Anr.wbd;r. from tha eeuaeA stated.
r ~ 22a St NATUR[ (LM/rtt M !L!N 21/. ADDRESS 22t, DATE S:GNED^
~e
• / ~c-L;.1/ ,~J, / ,;~c ;n. ;v, MacDi.11. Air Force Base Fla Dry ~sz
23. OUMA:. CRirATIp!r_ jab DATE 2Jr NAME OT CEME iLRY OP. CAE NiSTGRY 231 IGCAI:vK (fd/, ltrrl. N t01IRt~) (Stahl
tKrOtiAI LtitrnJ/1
Rernvi: , oc.30 19b8 " 1 Ccr_r.. Rrlin~~z 4'~ _
_ t:rlin~.,o:~ I~ra~_ona r ~4. _ _
2 jA,fUNtAAL DIAECTOR SSIGN4TUq£ ,
I x7i S~CBi`S°Ri~ri~ra s :+orZC ~ DATE RECD 0Y Loc.l REG 26. RE TR~A S SK.!IA vnE
r`=~-~v"i ~ ~ ~l~ ~a- r TaTi1~a,F14 :i.. ~ /tfC ~j I ~t /%'/~~l~' %t~
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a
6 I hereby certify the above to be a true and correct copy of_the Local
}Zcrgistrar's. r~s~4~ on file in the: Nillsborougl+ County }[ealtll rJepai•trr+ent at
1 umpa, Fear' •,~y (~tu~ning: Not valid unless raised seal of the }lillsborrnlgh
C'~unty, ~~,~~~Ii~'tlnent is affixed,,
~ I
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i~ •.ti~ 1
- : ' I' ~ ~ I~r Cou y }iealth`~afficc-~ Loca "Registrar .
~ APR 2 5' is~~ ~ ,
~ sate Deputy Regis ar
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