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saa ar Fluriel. CERTIFICATE OF DE/
DspsEtEnent of Neahh and !!eh•bili a Services F L O A I D A "s" nu .
VITAL STATISTICS ~ ecalsTllAS•s No
TvPE OR PRINT DECEASED-NMI[ - ra• .Ieelt utt SEtt DALE Of OEAM ~ »o»t", e.., .e•e.
PERMANENT I J DiBenedetto ~ 1•;ale , Jan 2 1 8
EILACK INK RACE en.Iw, reaeo, •rteK•w I4e1•», AGE-a•st Y»Ne / n•I Yw~.
t Nt CATE Of WM I.w»M, Nr, Cq~Tr Of pEATN t
etc. 1 weer. a enM nalsl sips es woues rea: nu t
e trhite ~ eAp~. 18 f 1908 Broxard _
I f„ I ~ f
m.
IOMM. O• IOCAT OEwtN wyN cew srrs AL Ot OTNER INST - rr »q Ut.u. 4M stMn ..w »Y..a t
/ U' wscr. ns p to
tliraa~ar Yes „ 6520 MiranEa~c Parkway. _ j
STATE W IIRM I r rOt w Y.e • , »•r1 CITIZEN Of vMAI COUeIriv MARRIED, NErER MAtlEO. SUtHIVNG SfOVSE iw ire, dne .aught were /
~ cowtes t O. EO I wet+? I
: R Ital~r • U. S. A. _ NnO~w`tai-r~e"D~` - „ I'iarie DeRosa
.~•to w N•M SOCUI SECUbTtI N11~r4E~` USUAL ott'U?AigN Ian acre a erpea eow eYe.Iw etpst
pp 1cIND O%
MISINESS O• M~1DUSitr'- - -
000VNIe M IeOM"'tti Ire, M» M rrwe 1
""""'1QN' 08 -0 -224 ~ ator -Starter „Elevator _
Ieowwel rtor
'Oi1s"O" RESIDEtvCE-STATE COUNTtI CITV, TOWN. OR LOCATION r+sne cm arllw STREET AN MNU ~
1 sever. eN at ILO
I~ F1oTida IA Brottard Iw M1ram8~T t.. Yes ,w 6520 liiramar Parkxay
fATNER-NAME trst ryNl ~ lug MOTNEt-AIAQEN NAME rrst r/epe ufe
is Alflred ' DiBenedett t~ria Era
1?1lORMAM-NAME ~ ~ MAR,MIG ADDRESS /meet pe a r.e. /10, C", a eo~rr, stew. t+1
c iarie DiBenedetto - 6520 Miramar ~arkwayf Miramar. Florida 33023
~ ~An I. OEAM wAS CAUSED sr: (EN?ER ONttr ONE CAUSE ?ER lpiE fOR hl. AL AND kll • » '
N rlene" acct erle N•
~ 1~ a, A~rocardial Infarction
a
coremors, n •.n,
rewltr o.ee .Ie. a nT Arteriosclerotic Heart Disease
Ituat NAte CAY•e /et, eM q, CN Af . CO»rOYleKe p:
et.tlMe tee YMIeF
ItteN tAYN /Aet
Icl
BART OTHER SIGe+IfIGwT CONDITIONS: cowowo»s coaweaYn.,e to ot•e¦ ew rapl rune ro c•Yr ~m» w+ rut I Ise AYTOf+311 • vES I.Iee rrwel»es cc•
fns 0• tIG1 elNre I» NteeM»We t.l•!
• Ends a Renal Failure -Dialysis Patient ?lo e'•'"
M~_
_ OR YMD[TEMIt}N[0 A /ro»tw, M.,.b.l NpW It1JYl~ OCCURRED /1»te. wryr p t»wn 1» rut t p r•n r, m. t11
i IfUURr wT wORR RACE Of RV1UR11 •t wo.r, r•er, secret, r•e~on, LOCATION 1 snue oe e.. • »O . un o. for", srr,te 1
t eeeeln ns oe riot owecr euc., etc: esreerrr 1 .
RIe IM M!
CERTMICATION- rpMr e•t nu .aolrw e•t n•e AM uu 3•r wr/re..eM O» 1 Meior •.ot .rw ep pt•t" OCCVReto •t rwe ?uee, o. rnt
fM~3KUN; TO r0•Itw M. wY eON •ewe N•ew IwOW r e•w, W, ro M N
1 .mwee twe 3~ •r•T Tn Jane 2 1 8 n, 12 0
Tse Ntt•NO repr • 9? 3 77 ,tepid-Not :I.S t00A ,A o ~.~`~,.°u:
~ CERTI[KATIOH-MEDKAI EIAAYNER OR CORONER: o» e.r e.as p ewe wow p N•w1 ewe NetNrw .•s reoaloYrrces et•e
es..er1•ttow p t1.r eon •.IeiM ewe w.+esere•no1/, w r, pawa0», rttwtw e•. n.e rote
N•wI occeerre o» er aw •.Ie ew ro tI11 uYr~s/ ureo.
CERTIFIER-NAME Itm 0e nwn - SIGNATURE
scale Oe twat DATE SIl',NED r•O•rM, e•t,
Tb $onald Schreiber, ti.D. r, o n~>~ ~i~-r~ .l' ~ / - 3 -
MA•RVG ADDRESS-CER,Iit•f serer a e.r o../o. an w ro.»
~ 4 0 0l ood vd Holl ood Florida tr 20
RURIAI, CREMATION, REMOVAL CEMETERY OR CREMATORY'-NAAI[ tOCATtON on o. eo... srn
~j I sretrr I
Tee _En_
t__om_bment _ _ TI.HollywOOd 1•ieuorial Garde tk _ HollywOOdR Florida
~I DATE / rp»rw, wt, nur FUNERAL NOME -NAME AND A(eDR[SS . serve o. , r o •r0 an m ro+», tr•et. I.r 1
~.1 Jan _5E 1 8 intter-Kir Cha 1 610 Miramar P F;i.ra~uar Fla. 2
~ ~ V.S. #6T2 %WERAI 91(-SrGH~ REG1SpIAR-SIGprAtufE . , OAR CrwEO.~ IOCAI erGesteAe
Rev. 7/76 ~ Te.l17 } ,w Jf ~ e! : h 1 ~I~ ~N ~ t r - i
• - • _ -
~ . ~ .
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i
~Y,~ CERTTFIF,D COPY
•~~'t'Y• '
I _.cer•Lf ~fi~e above to be a true and correct copy of the Local Registrar's
r cAtd~ ~ ~f~ ` 7 ~ ~
f Jae ~ ~{~t'~Broward County Health Department at Fort Lauderdale, Florida.
(~,1ding=NQt-validtlEtless raised seal of t e Bro card Co my alth De t. is affixed.)
•
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~ ~"rr;~~.~'r.~'`~~''_~~ County Health O ficer and Local Registrar
{ - • 1z 1 1i IMI~i111~
Y ~
r T' -
Chief eputy Local Regi tray -
491961
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.M. 8 ~ g 42
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