Loading...
HomeMy WebLinkAbout0185 , ~ . ~ ~ . _ ~ , y . S . ~0~0~~ . . . ? ~ ~ - . ~ ~~~el~h and R~ha~.ililatire ~etvic.~~ ' ~ STA7E FILE t~G. ~ ta~~riuv ~~t nr:v ui F L O:~ :YtF. OR ?t:t+T IN °11i~°°"•n'LR•T°i`s ~ . . . AEGiSTRAR•5~ \O. ~ - - ~EAMANINi INIi OfC'.~SFJ-N?MF ~~~ar ~ .~aa.t ~ .•s~ ' SEf X~M~f~Dt FGI jSEx OwiE Gf OEaTri ~+oh:.., p.r, ¦t~~ ~ - , l1~SitililiOYS ~ :`•~~TTfin,~I B'lri;~;~,li ~ ~ii~alE: ~ t~*JT'1 ~ _ 2~ IC72 - RACE'~+~:~I. ~~IG~O: ~rl~;Cui ~vDUe~, AGEy ~~5~ 4~~:lr t rta~ ~r.~tt ~~r ~ OA~i Of BiRT~: ~a+O~cw, o.r, ICOUNTY Of J~wTN ~ - ' - ~ eic. tir~c.~r~ ~~~rh•.~ ~~Uts~l-..os. ~ ewT ~S~tiJ,:~l i rr. ~ rt.~~ , _ - ~ :~:hit.e ~s.7~~ ~ ~s~ ~ !~~~97 ~Iay ?9 ~t. ~:artit.. - . - G~TY. iOv+N. OR tOCATtON Of Gf~i„ ~•s.o~ em ~~..~r~ }1OSPITAI O~Z OiMER WSTIT~jifON-NAME ~+o~ ~ti e~t~ee, eni ~r~ei= ~.w ~~+s~~ ~ ~ - ~ lIIC•11 1~3 OY NO { ' - i ~~taart ~ ~ '~t 11.5 I~/ ,';Gl Vlli il`1~~01 1CL~ ~GJUlUP1 ~ ~---'--F-----. r~.~---'-- ~ St~rE OF ~~atn ~u tio~ ~N u.s M~r~IClf•tEN Of WtUi CQiiNTZY ~titAiFlFD, A:VcR rURR.FD SUiY~Vk:G SPOJSE ~~r r~~, G~~t wwt~ k.+e ~ . ~ - ~ covM•~r~~ W~GOV;E~,DivOiCED~v~tur~ ~ . ~3~.,.~5:~~~~t ~::e~•~ Yorf . 1+ '.I~A ~:arri~d jF~ He1er, Calc : - o<<<.~~o - - - - - y~~-~p, ~ ~~~TM SOCIRI SECURITY h'Ul~MER 1~1SUAl OCCUPATh7N ~6.r: av~c o~ wwt oont G:.~+tia ~s~ o+ ~ Ks.YO OF bUS~N[SS OR W~USTAY • ~ : ' ' ote~uso .vo~ueo ur~. err. u~uueo i ~..~rai~:~~«, tn~ itn ~~i, ~ ~V p ' iis? r}i.r? ~ ~es~at~ce~~roi_ C 2~..-~~ ~k. 1 c~•rici~r. .,~C-' .•~"~si'o". R[S~DENCE-SiAiF COJMtt~ CtTY, IOWN.~OR tOCATION j"'~'~< <~TM ~~+~ii +StiEEt wrt~ ?+U.M~ER ' ~sre-~~~ r[s o~ .w~ . ~ ~~:'lnricia ~,S ~iartirr ~:~,~~'aart, Pura~ ~,~~1~0 1,,, ;~I~ Ca^il~~ S~ree~ _ fATME~-NA.Nf ~~~3~ . ~~.T7'.F . u3f iM'JTi1E2-hiAh7fnNAMF ---/~~SI r~~a! uft _ ~ t . ,f ~~ir.cer.~ Lo fi-~ance - i„ Josephir.e Par~.~.cre _ - _ IN~O~iM/Wi-lvAMf _ - MAKL\G AL:ik[5S ~Sr~l~t Je ~ f.c. :.0.. C~i~ O~ iOY,+. 5'~*4, tu~ ~ " iic182: Biarcc !,j~Co:;~Z .3 Poir~ciar.2 Garde:eS~ S~U2:`~ - ?wkt DEwirf w~S UUSED 6Y: . ;Fr+~fa Oti;Y Ur+[ CRUSE tu~F ?GR o;, ;t , ~r.D ~~~~Q+y~'~ f ) ~ur,.u.: o..st~ ,~a cs.r., ~....eo...i uese • ' • FI~t~ ~ : .v ~ n t~~ :~L-t%1 ~~;~7:~'~-;~-~' ~~~.,j~jJ'~~ ST.LUCit i.t)I:HTtf FL~1. r' =u'T~aS } 7S'-'''/- ~ s'v!'t~u. f otia~w~-a o,. v F R C~~~ :~.~1i t ~ t ( / ~i~/% / . coHa~,~o..s. „ .r.,. ( b L~~it1;, ; Lv G ,~,~~,~v~ S ~ U`~i' ~=,,~.=-YY . ` ~ - ~ w~:c~ o.v~ nse co ~ 1 I ~ ~ wl:t~iE C~Yf! 1Je, OVF t0. Ot ~f a COHSlWlr:t! ~I: Sf~tING inl uwDlt• ,.,~o ~.~3~ i ~ _ Mai I !t ~M'75~~0 _ <<, , 9~ ~ PAAT Y. OTNEQ 5 KANT CONatiIONS c~.x/.:ns to -~,~u'~~.i, *o e[.r~ .~O+,tl~~tcD tG Cwu:F GYt~. r~~l ~ tp~ - {AUTO/SY { tF Y~S we~t ~~rin.~~s cG.- ~ . /~f~/ ~t ) 7 ~ I/lEi O~ ~OI 1 ='~~i~[~ In t!Tl~yiM~~.G C?uSF - v~ j;. ~J . f Its - - . ~ 6VLIIL~? C/~' ' ~ i/'lf~ ~ -:f ~L~~~~.~/~..1 . !Ih ~V G or Di~iw . ~ '7.oaat:il ~CGDErti. S1K~DE O'a iD~TE bf W;~ ~..a.rw, o.v, ii,a. IMC~VR `nOW itR1URY OtCUk~2i0 ~ er.'t~ ~~T~vF O~ ~~:1i~i ~r. rw~r ~ O~ r.~: ner ~t s iYJ+~t.GDE; Q2 ur~~ETEiMit:tO ~ . ~ `Sxc.F~l - _ . - - - ~ - - ~ •23i t::c. ~ M ' T;1 ~ ItrlitAY AT WC~.K . F1ACf Of W)~RY.r nO~e. ~•t., ;rittr, r.ero~s, r~GUT~pT1 ~ - ~~'~«i O~ ~~.o ..o., tnr c~ ro.r., sr.it, ISrF[~n ~i{ o~ w01 G1rtCt l:~G.,lK. 13r1C.~~1 ~ - ' . r.~ Irr_ ~t.: _ . ~ - ~ CERiIfIU7K3N-- Mo~.rn Dat ~1~~ ~ ~.~...n Yl~t ~~r.D t~1r Lw n:~~nl1 wli.! O~. -~~:.N/L.~ r-01 ~:F'n f~(3p[~'H +.iGC~liFO ?t t+! ~.•C[. G-:'. - /tITSIC1aN: rGti'n C~r TI~~ .IGC~! ~11lI G[~rn. ~~n:~i~1~ :J ~.i 1::• . C~t 1- Z,~ ) ro ~ : ~ _ ; , .~,~,f~.r.:,~ 7'a ~.t.sea ~.u..u'"~ ~ / -r .2~; , ~ ? % r~~..l J i~ ~ j ~L-~U t.~ , I ~7~~~ / t. J 7:~ ~M. 10 C~'.: tEatif~GltOU-x.FDKw: EXww~~r.ER OR COiGui:.. o.. ~~~::s r~e w~;,. o. ce.~+ ' 1~~ e~.r:t.r ..,s •~o.o-~•.cia .e.o ~ ~ [c~..:~a~'.p+: Gt :r~t ~OOi ~hD~O~ [n[ u.v!)l~~~t~.n, rii W.ne(.«, ~ ~ rO~.tw O~t ~F~¦ _ n'v.i ' ~~`s"~- Cl~Tw O:C~.~+FJ b~ r.[ O~Tt ~+D Dtit It7 ~wl C~~lE•S~ S~~r ^ ' '~'(1'~~~ i. r/ }J 2:e . 10. ~M1~.~ . . 3_f I • l!. ~ CERTIF1"c.Z ~tAVE mri o~ ~~wn i S~GN~HJ:Ef~- ~ o~u~ o~ r~r;r, OwTE S:G:.:U c.•. ~i•i~ - ~z. J ~.s ~C. r~ ;J ~ ~;L ~-r~-t ~ ~ ~ ~'/c, y~~t.. t) . z Mw(:IN^ i55 CEt tF4 l• i~ o. ~.i:,. ~ . c, u rc~ _ =•.:i r.. - , _i/ ii~~~~~ v~/=%~ ~;;!~FP r~:~~~~~1~' ~~c~,~i %l - {U~~xC. CCfK~Th7N. RE~.tOVql ~CEI+tiTERY O~t CREx.~tGRY-tl~v.~tl ~ ~:A+cTr07+ t " t~n oe :o... it.zt - - - - ~ t S~tC~h ~ ' ~ - - ~@^1OV21.' . 7,n lJJ t:T'EL-i~t1UY: i.C 2:~;-i1C~C~i@ lli2~~',@ ~ vGT'~~ - _ ~ ~c .~-~`,~5~-' OAif ~..o.r.w, e~t, .e.~~ . FUf.Ep~l HC.NE-N~v: ~np ~pOFF55 ~ s*~e~r c. ~.~.e. ~o., us~ o~ row.., sr..e r~r ~ - - _ ~ ~ca':?V 1 1972 ~~s~ cj0~'tT'iS ~1:'_":E.'3"2i u0:?:P ~tti?T't~ f~G:1C~~ 3349Y - , Y• S. ifiiZ FijtiERAi ,D!i~J((~t-S7 A?URE - hiGiS72AR-S1~,.':A7U?F ~D~if /?[;~E~YFJ ~7r IGC~i :[G~Sii~R ~ Rev.191G 1if yL~ t ~,:.-i . <rf_~?;ta/.~/t_ t / - , ll _ ` t l; %>,~i~~, - . . ~ _ _ ~ ' -f/~ 11:~ ~rj1.--~ . ' , ~ ~ . _ - ti._ ! htreby certify t5;s to be a truo and correct ceoy of tr~ Laa~ . _ _ ~,rJ: • R~+s~rar's re~ord on file in the h9art~n Co~~~ty Hea;th Do~art- * ~f_ T~;~• - ~ frtBM at .Stuaf:, F10fidd. _ _ • _ _ , ~ ~r. ~WJ(fiiflC_j: I~:O!-Y.i~~G Uf1'.~5~ f.~i^_!~(j $P•3~ Of lfif' i~~art~n ~ i . ~ ~~j } ; Caun:y Naa;;h rJ~p~rt: _~tt ,;fiixcd.) . ,r r.: ~ . 1,?~~~:~~•~ - . - _ . ~ ~ if .r1.. 3 4i: z ~s ~iz~ f a h fa ~ - ' i . ~ . - ~ .`/.ic~ls ~~e ~t~S: 1~ ~ - - - Q.'fi~ ~1 CC~y ~~I. V. - - . ' }tJ~ ~y~2V;~~ ~ _ . _ ~l1 r :j ~ ( .>t . ~C'uG:~ ri.ditJl Vti:CAf Fw ~OCo{ ~hA~i5if3; • - ,~a'''`-. " - ~ - ~ ~ ~ ~ . . ' ` f ~7t= .~~/a'us-~ ~1/ ~ t~ . / /~iif_(~~~ - . ' s _ - 'f~ Gay.uty t.ACbl Regi~tra~ ~ ~ ~ ~OOK~~~ PAGE _ ,