HomeMy WebLinkAbout0923 i s ; f : ' : CERTIFICATION OF INSURANCE POLICY
sate of-- hlorida county or-Saint Zneie
I hereby certify that I have ezamined the original insurance policy issued to_-.-------------~-.--
----1KOAt_E• Sii~de~.i~
bySonthern Zits ~ Health Ins Company, of Bi r•! ~n~Alsba>l~a .
The policy number is 9742999 ~+d was issued on_ Deoeaber ~ e 197.-_.
The following is the e~nac~t information as shown in the policy:
Date of birth or age_--__~=2-
Is a,ge listed above described by policy as age at Wert birthday' __a__Yea. -_-No
Place of B;rth Hot Shotin Qn ~n1_
ie~
Name of Beneficiary--9111e Z Sanders
E The policy is now in the poaaeasion of_._~~~~ Ti. Sandal's
whose adaress ia_Rt. 4, Bon 287, Ft. Pierce, Fl._!_-
I ~
Signed this__.~~day of - fr--3._-~ 19~
r
Sign - "
e Title of
- - - .HEAL - ' . Certifying O~oer - .
_ - ~L1f8T: a]~ PLACED ~'lM? 514 ~ ~e ~ 1~
ti ~ Q ~ F~: ~ - My Commission Ezpires ~ 6itias~~. 16. 198j `
'r^ ~NO " ` . - Address of o?30~ . ,j"3
r~1 _ . - Ciertlfying C?~~Cl[//r//_.._
- _
z ~ 1980 AUG -7 PN ~ 07
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495509
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