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HomeMy WebLinkAbout0347 ~ - a-, - . - . . _ _ _r _ . . . .wa~~ ,~':'i ; ~~,.-~Y . ~ ~ r. ~ • + t . i _ ' . - , . . , Y T ~~r. . ~ _ ~ 7f . , ' . ~ . ~ D~-'~.DP3 CUUNTY t"~ - . . . . . _ . - ~3EPARTMF~NT ~1~` PL78LI17 HI~IrI'H ~ . . 1350 N. ~V. FOURTSEN-S1'RBET• . - - _ . . MIAMI~ FIA~kYDa~ 89~1a'f . ~ :a ~ _ - . _ ; I~E~APTMENT ~F HEALTH 8r REHABiLITATIV~E SBRV[GES • . ~ - - _ - DIVI3ION_ OF HEALTH ~ 's ~ ~ ~ < _ . . . . ~•~p';p - .j _ s ~'.~aa:~., . MILTON lAf1.Aw. MQ. Mrtl. dIRtCTOR l- _ ; r~ ~ r.~.._ ? 1~~: ~~p ~f TO BE ~ TFdJE COPY OF' TEIS ~IiOCAL I~GI3TR1~lR' S~1~ Ll~! ~ ~ i . ~ sf.~, t ~ _ . _ _ ~ - i ~ ~ ax ~ ~ • J. r i. . t ' . - . - . ` - - ~ ~ . .ti~ess ~th~ raised seal P[l'I'Y R'~GIS . ~ . _ ' , =k , s _ - - 4 -ti= {~A~:ii~f gital Sta~isfi.i.c~ VITAL 1~CQim-S_ UNI; . I.- > 'Y~' s . . _ ° r,~ - s~ ~ ) ; ~ . - . . _ MIlyMI ~ FLORIL~A - ' " . ~ ~ : .^~is ' 13 y"•'~. ~T . . ; ` : . . . . . _ - . . ~ ' ~ : ~ ~ -r •.~,~,-;~.~E~T1F'ICATE 4~ UEkTH ~ ~ ~ _ . ~ ; f . ~ ~ r ' F L O R I D A - ~:~t~ ~~~c wo. ~ - : ' - ~ :H r -<< .f~~'~~__• - REGI~TRAR•! HO, Us~~ ~t T,. yarooit ~~ft SEX ' OATE Of OfwTH ~~ON1M, o~*, re~e i ~ DECE ~ = ir . t _ ~ M y Tc ~ % --~Tr ~ ~ ~iYit-'~~vs - : v R11CE_ w~. Mtt.w:. ' uRft:3. uwe~ ~ rew~ urote ~ o.~ DATE OF ~IRiTi i w~n~. a~. COt)tiTlf Of DEATH - . t IIc. ~ s~tc~n ~ i_>' ~ln~0+t T~t~ts ~ ros. o~rs nwes r.s~. •tw~ ~ . t - ~ ~ Itl~ITE k ~ " Dnn~ _ - _ CtTY. TO~. OR IOUTiOM OF OfAM . ~+sxt c~.~ irr,s S10SMAL ORO%~R ~TR -NA/NE ~n ewT ~H ~uKe~, cne s*aeE~ uo Nuw~~ ~ ~ _ sna~. res oe no ` ~ 1~1YA!~I ~ = - ET~RAirS AbM1N IOt~N~PI~AL-_ - ~ STATE OF NRfH ~ u Not ~M v.s.w., N~~[ CiTIZEN OF WNAT tOt1NTR,Y MkRR1ED, NEVER MARR~ED, SURVivNG SPOVSf ~~r ~+:r[, crlt ~uiaM ~awt ~ • can+m i w1DOwED. DtYOiRCtO ~ sm~r. ~ r~. II.tINOIS tl S A ~ IfD ,~_?~IARIAtI~Y ~ . ~ $pCtAl SECURITY t~1M6ER USVAt OCC1lIATION ic,rv[ ~wo ot xptt oOr+c Dtt~~~ ~as~ oe KINO OF lUSWESS O~ ~NDU5171Y ~ ~ _ . r0[[u~G L'1E. M+~ tr tEt~~ED i . ~ 332•09-536I - IItCRA I ' M=„~ ~~TM iwRy S~REET~ANO WiI+VfR ~ RESWEr1[f-Sr~TE COtJNnr Cmr. tOwt~. O~ ~ocsT~Uri . . . - . . ~ ISI'FCHT fE5 O! MOI . - ' - . ~ i FL~tIDA - ST.L7CI F R ~ ~ ~ fATFtER-NM~F r~est uroou ust AK?THER-MAWEN NAME ~KSr .uooct ust - ~ ~s - - NENRY ~ " - BRUGr - ~ ~ ~ ~ ~ INFORMAiJT-NAA4E - MAaMG ADGRfSS ~stn[r o~ ~.t o. ~+o.. tm w*ow.,. sr~n, ir. - - r VA NOSPITAL ~tECQRQS 1201 t~ ~,6th.~?RE~T,MIB~RI ~E't D~ QA 33]2~ , ~ , . .r.tai~rw ~N ~ fART 1. ~i}ATH WAS GUSED 6Y: [EN1ER Otl(Y Ovf CAUSE iER lWf fOR (u}, (b). AND (c)j fFTrIE~N OMs~r ~.ro a~t,~ ~ - •I _ a.,~ta~,re uus~ ~1L ' FLA. ~ - s7_ ~.uc?t couKtY , ASPIRATIORS aRONCHOPNEUT A SI T aoct~ Qo~z~AS . . , M,~~ o~: - ctERR ~ . . _ - . . _ ~ - . :pFr,.ca ~ YERtFtED p.~, MMI'CNt6• ~ o ce~ - ACUTE AND CNRONIG PYELOh'EPHI?IS . . . . . . _ ~ - - ~ _ Irrt0l~lE C~uff ~o), 6tit TO. W af ~ COKStOU[~K! W: . - . : s~.t,~~ ~~o~.. _ l+lar 3'0_ 2 la ~ - ~~ING C~Yf[ 111St_ - ' ~ - ~ . ~ ?ARi tl. OT11E! SIGN1fICANI CCNOITlONS_ cor+wr~oNs cane,~vr~~ to 6t~ns ~vt ~+ot aiareo to t~ust ~ntH ~H r~~~ ~ to~ - ~~T 1F YES Kt~! nMO~w~s to~- - . . Ir[S Ot ?WI f~O1~lD IN 01[l7rtr~t:~6 GVft ~ . - . . . - - , O~ O[wt . . - . _ . ~ • Ifs - N? - ~ ~ pr~boW~1 ACGDfHT, WlCfDE Ot D/t NJURY tronTN, o~~, re.ui ?ir.)UR HOW INWR1f OCCURRED /(NiF~ lVTISt[ Oi INIYR IN Il~11 0! fdtl n, rttr ~t~ ; ~pA11qpE; Ot UNGEiEHAtNED s ~h! ~ - - ~ M ~ • ' . - iNUt7RY ,1i VIpORf( ISACE Of MMY.~ wo..c, r~~r, sr~ecr, r~aorr. IOC~TION ~ smti w a.~_o. ~o., cm oi ro•m, :*~n ~ , ~ ~+ean r:i w.+o ~ onKC Kcc., eY ~ s:ean r - , ~ ~ - - . ~ , . _ ~ - ~ERIIftCwiqN- +,o~+rM o.~ rE.~ roNe, o.. i[e~ • w+,0 4Sf Lw efr/rt\ ~?int ~1 ~ ao~ao ~.or ncw na Dt~n~ eteutece .r me w.a. o., w ~O ~NrsKUw: = ~ - . ~o~+n~ o~i rt~r wor ,?ma otetn. ~no~t: . a~rt, axn. r.? s:t ~[f~ - . d ~ ~ wntr+oFO t~ tiA~.] ~ 4 1974 iN. ro mt c~ustR~ st~~[v. ~ JUN 3~ 1974 ` ~~°:i~AUG.4 • 19I4 r' Not ~N°w"°~, a„' o~v t1a. ace.seo rror ~ v: v~~ CERTEIG?TION-1~E~~C1?L ExAMMiEt Ok CORO~~E4: o.~ n~ us~s os nrt wov~ er oE.:~ rN[ atta.rt ...s o ouo ~ ~ ~IAaM~f1~1A O/ DI ~001 /iMOIO~ ~IK WfESTIrMT~OM. IM M~ OIRi~ON. . MW~Z11 Ol1 ` 7T~t ` ~ MOf/~ ot~rn occvmo av nK wrt iwD out ro.rwt c•vu~s~ sr,.no. ~ ~ ~ ~ - - - ~ -s i~ . _ ~ ~ Ml 77~ - ~ _ ~ M. CERTIFlER--t+u~f mn ~ rtn~i~ S~GNA~URE ot~~rr o~ rmt ~DRTE SSGY.:D s~a.r+~, o,r,~t~a~ ~ 12~. 27r. ~ ' l ?k _~Z~ ~ T ~~~w~,~,~~irf~~~ISTRATION HOSPEtTA ~2~i 16 ST~ s'~'~ z~ ~ - ~ WRIAL. ClEh{ATION. REFiQVAI EMETERY OR CRfMA?ORT-T/MAE IOCAitOli t~1 w qwn~ • sure 1 f/lCOf 1 - }k ~ ~ `+S`_ ~ :wRenav~l.Crema i~on F~erce Crer~atA~ - DA1E rwnN, t~r, rt•~~ A FUIVERAL H6MF-NMi[ R?~O ADDRE55 ~ StHtt Ot ~!-O. r~C , cm o~ ro«?~, s~~tt, rn ~ a= - ~y ~ ~ 1 ~~~C~ r ' ~r~~ . f R=SK.NA RfGI AR- GrI~ 1E tft ED ~i t wt lEGttft~t - - ~ rA ~'t~i ri. ~ -