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HomeMy WebLinkAbout1474 3 , ` • . . ~ 1 S . , _ . . . . ' t~ ~ . ~ .a:..i... • : 1 ' . , ~ HYUY.S1301t0UGH CbUNT~ }~£AI.Ti{ ti~PAR~MENT :L~~~S~ I ~ ' ' 7.42Q Tampa Street ~ P.O. Box 17~1. plant City . ~7ohn S. Ne3~.x, M.D. ,M.P.H. ~ • ~ ~ ~ ; . ; ~ Uir~c~kor ~ Tampa 1, Florida Coun~y OF£ice Bldg.` ~ ' ~ -V ; Y7AYt ~OARO o~? H~~.rn ~ CERT(~'1CA'T~ C)t= [~EA'I°H . . . • ; t1UA~J1V AF VIYAl. bTA710Y1Ce 6TA7G t'IL~ NO. ' • ' • QIRYN ND. ~ . F ~ O ~ Y U A ~ qga16TRAR~6 NO. ~ j ~ ` ' ~ ' . USVAl, q[NOLNC[ N ~ 1. r C[ O? OtATM CO[~R N~. ( ~~~f~wtJRrd. //l~~~eri~+: XM~IApWR1 fIqL1~N~ • ~ a. STAT[ 0. COVHTY + j•. °""T'~ Hi.llsbaro h ~ 39-pG2 Flor~.da ' t{;i.llsborourh ~ i ~ 'i 0. CITY, Tp1YN.OR LOtATiON t. 13 ?LACE OF OEATN t, hTY, TOWN.OA IOCATqN t• IS 4tS10[NCE ~ ~ f' tllltC[ Y UMITt1 lNSip[ CITY tIM~ ft j S ~ ~N~1 ~L YES ~ NO eI ~lti2i YES CI NO G;} i ~ ~ MA?~f a (IJwKla~apuN,f~+<<h~tts!lrcu) IEhGTH OF STa[ET AODRE55 OH A fAIIMI ' NOS11TAl OR SYAY (t4 10 { ~ INSTITUTfON ~ Z` YLS Q Np ~ I ~.3~ St. Jo..eph }ios ~tr~l 1 r.un. Rt. ~ Do~ J.6t+ ~ ' ~ t occr.~i~ico tY'~t /Ulfdt~ ts~t o~TC J?tostA Do~ )~e? ! ~ ~ i,# t trr~.•p•r~r~ GEOR `r FULTON Hl11~~,YN a TH August 2~ 1961E i Y ~ S. f[X 6_ COICR OR.IIACE 7. 8. DJ?TE OF ~IRTH 9. AGE (1~1 ~lp1 ~~aR 1 rCAR Uhp[R 21 IYtS. MARIItfD ItEYCRMAnRICOO JsdO&lllo~) X~++~, p,r, K,,,,i xw ` Z%a].~ ;'~Li.te w~r,owco? avantco Oatobar ~.0 l8 ~ ~ ~ 10r. VSUAL OCCUtATWN (Qtr~ ?Iq1 eJ~a! dont IQD,lCq1DQf ~USINESSOA ItiOUSTRY 11. i111TM?LACE (Stalt 0I /pttl~~ tOrahr) 12• C1TItEit Of vH+~T C04Ni1tTi i ~ ~ f drrta~ w~ety rNlf~/ I~Ii. ~~rs lf ~/ffrt() ~ R. ent Frtut ress Co t:ont arner A?.absma U~A ~ ;3 13. fA~11E11'S 1tA?S[ 11. MOTH[R'S MAIOEN ILIME . {{{i1 S~r.ntel H, vn 1•?.attie i`atthew ' ~ ~J ; IS MAS D[CtA5E0 iY[R IM Y. A ARMCO IOAC[ST IS. SOCIAi S[tURITY IfO. U. tK?ORr~ANT i i1CHA7U/1E e ' ;.'1 . • • 11'N. w~~1y~1 lfJyr~. f~p Mi r A4~ ~l aen~.1 y'~.. I / ~ 7`; ~ ~ Yos i~r.~1 ,~~d.~,..y,P~~ ~ ~;~,^r. ~ , L«t~ t ~ 1~. CAYt[ Ci CtAYM (B~lc~ onf/ snt aru yt~ltiu~ (bj. ~+t! (t?.~ ~ • IMT[RYAI OETW[[M ~ART L O[ATN WAS CAUS[D OYi 'l, - OKSET ANO OEATN ' IMMtD1ATC GllJSE ~F"?~ ! '•F ~ " _ t ~ f • ~ ~ ~ ~ ~ ka te~~. ~/.Ar. auc to ~e) ~stt rt~~ te ~ j aDae carlt ~ • „ , i F' ~ Nrtia/ f~t rs[rr. DUE TO (e),,,,_~ € ; z 1/!a/ t~rx fo~f. ~ O ?A11T p. OiNCn Sx~aKAxr Ca~anons corrrRUViv+C T Oani Ovr ko~ R[uTto to Txt t[~KUUI Duusc CoNarqrt Gtv[K Yt tlu~t 1(y . W~tS.tUTOPSY 3 ~ ~ { ?EIliO1lNE01 u TES Q MO ~ ~ 4 ~p,~. ~r~ e 2QD. ptSCit1YE llOw utJU4Y OCCU11RE0. (~r~r *w~r~ •~~,~~?~r t,~ ~.?t ~w ~.rr J! y~r~a tt~ ~ 'f ~ ACCIaqT S!!IClDE HpYKfOE t.`;~ ~ J O p D ' - ~ ~ ~ ~ ~L. YlA1[ OF //~~1/ ~~Af~~ Df/~ YtN ~ uuuaY ' ~ : o y. ai. ~ ~~C 201. tNJItRr OCGURR[0 ~Ot, P~ACE Of tNJU1lT a eiWr! jeau, 20J. CITY. TOYlN. OR LOCAYqN COVNTY f7ATE ~ - ` MO K AT Q NoT w~HiL[ O /w~.l~ari +~?~N. ~jjfee btt~.. We.) ' . _ . " ~ ` ~ ~ 2~• 1 ~e~~nd~d th~ d~eaaa~dlrom ~ , ~o ~ •nd laaf ~a~r ~ ~ aliv~ on ~ B~~fAxeur~~d et ' m on fh~ d~ts sf~f~d ~Dor~; ~nd to th~ 6e~t ol a~ Rno+vi~d/~, from ah• o.u•., •e•r.d. } ~ 22~. 16NATYiI 1~n a t t~) 220. AOWIESS ttc. O~T~S~MED t ~ . ~ .f~ . s t. - ~ d e Hta. Qa~t~-~-stic,q , ~ t 3 ~ ~ 2J~. W~ai~, GttwATloN. " i1TE 23t. NAME Of UM[T[RY OR GREMATCRY _ 23d, LpCATIOt/ (GV~, Npf1, N t1a~!/) (BT~ft) • Itc~OYU Sp~liJ~) ~ ' ' Ro~~ov 8- --6 E7r.it~rood Cemete ~ Jefferson Co, 'Alab~ma ~ ~ ~ ~ ' j( NERAL DtRIG 0 SIG 7URE ~ppREU T~~ r 2$, pATE RECO, iY I.OC1LL IlE6. 26. REG~3TRM'S SIrNJ1711RE . . ~ ~ ~ 1+UtiZi~ 1'~• ~ . . '~'u r~`~ ~lcC ~ F.T. Blount Co. ~ Au st 4 1964 ~ ~ - . ~ - - - - - . . . . . . . . _ _ , _ $ • : ` - . . ~ ~ ~ . ~ .i ~ . : : s ~ , , , ~ hereby cer~~£y~~s~ ~above to be a true and ~ correct copy of the Loeal ~ ~ . ~ ~ ~ Registrar's ~at~s~ ~a1r~ •~,e in the Hillsborough County Health Department at ' ? Tampa,Flori~,~,~ AR Q•' ~ Not valid unless raised seal of the Hillsborough, i~ ~ ~ ~ County Nes2~t~.~ t~+eAt'i~. aff~.xed. . ~ ~ , . . = ; . • ? : .a~ ~ ~ ~ . _ . ' S : ' ~ ~ ~ ; M ~ * r. ~ t ~ ' e s . . ~ . . " r . . . ~ ~ ~ ` M ~ ~ a N.~.~ • . ( ~ • ~ . . . . ; .'r. ~ ~ • ~ r ~i ~ ~ ~ • i , . ~ J;,.vr ~ f~ ; ~ : •i ~J/ .~y ~ ~ Z ~ ; . vJ ~ . ~,,~.w° : . Co y Health Offieer and Loeal Regis~rar ~ ; ; . ~ ~ . ~ . , . ~ . _ . ~ f ~ : : ~ . ~ ' ~ 0 ~ ~ ; ~~~.s':~ _ . • ' ~ : ~ ••..s~• • - ~ . . ~•4 . . ~ , : ~1;SEP 11-~19 ~ ~ . ~ ~ . ~ . . , i: ~ ~ i ate • ep y RQgistrar . . _ : . 3~,4` . .f , • . , ' _ . - - ~''+.~I~_ _ . ~ • ~ . . v. . . 'f - ~ . . - ~ F ~ . . . ~ ~ . ~ ' . - - _ ~ . ~ ~ ~ . . ~ =13~38~ ~ , . - . . ~ . ~ . , . ~,~"'`"t'~"- ~ ~ ~ : F ~ RECORpF ; _ . G~. ~ ~ p , , ~ . . B~oK. , ~ } { : ~ : :t . a l96~ ~ ~ ~ --w. K- - i _ : _ , ~ ~ ~ DE~ -9 p~ 2; . ~ ' g : ~ ~ RD~E ~ ~ # * • ~ ~.M? ~ ' : ~ ~ ~ ~ P01~' ~ ~ ~ ' ~ - ~ ~ s,~, ~~a , ` ~ ST. tUCt~ CO!? ~~S• a~ ~ "„a ~ Njr ftORt , - ~ , _ ' 1AM1A f . ' . ~ , ~ j = " ft0!t1~A--~. ~ t 1. ~ ~ . ~~~~K 1Q~ fac.F27~: - . ~ . . - _ , . . . . . . _ - - - - i -