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HomeMy WebLinkAbout1182 ! . . _ _ - _ _ . - - _ . . _ _ _ _ - . -~Y ~'ERTIFICATE OF pE~',TH Thls De- ~TATE BOARD GF HEAtTTi~t • ~ eo~es a ~UR[AU OF VITA~ lTATIATICf tTATE FIL[ NO. ~ ~~a4~ re~- FLORTDA . o~d sAti? " BIRTH N~- R[GISTRAR•5 N0. pTOperlr L I4~CQ OF 0[AT~I CODE No. 2. usv~~ Rct~o[KC[IRA~.~«.«.~t~.~ /!ititi~.t~~+~ R~~l.aa~r/~.~at•....:«~) ~xeCUt~d o. STATE D. COUNTT - .~a .111 0• COL'NTY Bro`~,~d ~'lorida Broward : D~ plaeed ~p p~~_ 0. UTY.TOWN,ORIOCATION t. IS PIACE OF DEATM C. CITY.TOWM,OR LOCATION t. IS pfS~DEMCE Hallandale - . ~ "~S~ ~Y `;~p Pembroke Pc`Z.Y.'iC IYES~~TYNO~~~~Qt rii.. NAME OF (!/not ea Aapud, /in elttN aitrtl~) d. STIIEET ADDRCSS ~"S~T~Tb Golden Isles ~ospital - 301 I~Iarine Drive 3 NAM[ 0? Fl'rit ~ 1lldd/t Lat( ~ 1 OATE Mo+t~11 - De~ Ytcr `p,;,,~~ TH~~ IAS J• 1'~HITF OEATH June 13 ,1969 - S SEX 6 COiOR OR RACE ' yARR~FO NEvE(i MARRiED ? b DATE OF EIATH 9 AGE (/n yto?1 ~h~R ~ Y~R F V„Df.l ti ?aS AZale ;y'hita June 3,1902 r~e~.~~aa~, w.,~.. D.p . • r i e• wiooweo ~ owoaeeo ' pltlnlj _ ~QQ_ USUAIOCCUPATqN(CiretinJo/rcor+~font IO~.KIh~OFBUSiXES50RIM~USTRY 11. BINTHPLACEI~aItOS/Ortlpq[O~M1I?~) 12..untuvosrnutcou+rnrr •!th pir- durinp mat oJ~ra?tl+rPt~)r. «rn t/?dirtd) ~ - ¦aa~r.t f ~T$ tr ~ 'a ~ ~ NeV7 York U • ~J • blatk int - FATltER'S M?Mf ~ ~ . ~ _ 1~- MOTHER'S MAIOEN NAME ' o~ . typ~*r~t« ' b-f- - UTlObt. - 16 SOCIAL SECURITY lw~. 17. IMfORMAlIT ! SIGMATYIIE . At~tu - 0g3-20--721 i~ir.Tee i~~an~ing 301-:•Iarine ~rive,yark Zalce =states,~~la. - lun~ral 14 C~UK 0I DiATI! [Enttr on!/ one cauu per li r(o), (~i), ond (c).J - - IMTERYAI EETWEFM d1~~~toT IART1.0lATXWI~SCAVSFDSY~ ' ~ • I OMSETAMOOEATN ~ . !MVS9'A~E LAl'S£ ;s) . ~~z~ ~ ~l~ ~i"~ - iust fll• _ _ - _ tA• e~~- ' ~ ~ ~ ~ , / ~ t 1 f! e a t• . Cendi/io~u. iJ ~I. pUE TO b) -~1CA th• ~vAicA oart ?i~p to ~ Ir 1 o c-a l oDae rauu (a). - ' - Y - ~ re +stra~ K~i~~ fRt nuQn- ~ - - . a' ~ l~ia0 tauis loaf. ~+E TO - • 1 tAl n 7Z ~ p,~RT il. OTHfR SIGI6FICA~'(T COMqT10hS CONT7tt~TlMG t0 OGTN ~.fT NOT PEUITED TO TNE TERMtY~1L DISEASE COMOITtON GhTM IM IIIIT 1(q) . WAS AUTOPSY ~ . ; houre •f- 1- ' . - tERfORMEO* t~t death V _ • ~ YES ? ?A ~ ot D~Core i. ~~~ae ) ~ 20~ mb. OESCRiSE ~iOW tMJURY OCCURREO. (Enf~r nol4r~ oJinjur/ in Parl I or py! 11 oJtt~m ~I~) •aklna •n~ M~ ACCIDEMT . SUItIDE ~ HOIMiCIDE . - dltDosl- W ~ ~ _ - . tlon , o! _ 20t TWE OF ilodr JfontA, Oq, }ia~ - - - aoa~. V ' INJCNY o. _ . - - i ~ - - ~ - . p- . ' . ' ~ ~ . - - . W ~ r ~ 20d. InJURT OCCURqEO 2Ae. PU[E UF INJURY (t_'., in or aAOUt Nomt, ZO/ CiTY. TOWN. CR lOGT10X COUNTIf _ STATE - 1MMILE AT ~ NOT Wtii~F /ar~, f~orf. tirirl. o,~ice D1dJ.. rtt.) ~ ~ _ IMORK AT 1YORK ~ ~ ~ - ' ~ ~ t 21. I~tfinded ths d+esea~d /~om , fo r ~ •nd /~et aa~v h~m ~/ire on ~ / ~ D~~th xt~tred wt ~ ' tr? on ths d ~e~tsd abor~; ~nd to th~ b~at o! m~ knor/~d/s, om ths c~ua~a ataG~d. are totDe` ~ fIQN URE i Or~ ~tUlr) 22b A~DRESS 12t~ OATEStGKEP ~o.p~e« ~ - j -;.,..L:.- ~ - ~ ;11~ ~~-~y. ~ •CCU~it~ ZY~ BUitAI. CREI~~Tk1!1 ~i OATE . NAME OF C METERV OR faEMil ORY _ 23d. LOCATqN (Ctlp, l9tt'o, Or ~pftD!/) (Sla1t1 • REMGY~I~l r/~1 } ~ ~ -3~ri~F`~. 6 16 6 Lauderc?ale i~_em.P~r~ ~t.Zauder.~ale,fila. _ V. S, ~012 4 FUtiEA l Ot ECTO~ SSIGM/1TURE AOOgf55 ~ - 2 D~ITE RECD. BY tOCAI REG. M REGISJ FAR~S 5 G;~T RE ~ ~ .l J - / ,J~ ~ ~ ~ ~ fier.1963 ~'r~.• ~ ~ ~-4tL/.~-`Y~ `~~C~,~~ '~'1"~~ T I /~(O! /I~..GJ--1i"~ ~~(-LrG~.C.iJ'J .iG~' i i CERTIFIED CQPY . - I hereby certify the above to be a true and correct copy of the Local 3'~~~a3 . Registrar's record on file in ~he Broward C~unty Health Department at ~ • - Fort Lauder3ale, Florida. . . ~ or ~M1~ ~ . d o ~ 7or~~ ~ (4tarnin idot valid unlzss raised seal of the Br~ward Gounty Hea~th *`~~rn~'~ 8~ - ao_xr•,t : : ~ s t i . ~'e~'iment is affixed. ) _ : ~ ~ ;ro~o ~ F rnco°s • . _ . . _ ~ , • _ _ - . - _ ~ C~ ~ i ~ ~ _ ~ fi-. eY ~ L C ~ i/~ - _ - 1 f~A - - ~ ~ . . ~ itC ~ . - _ >V . ~ ~ ~ 1 e,~ .../~I • ~ V~ . s - : ~ ounty Health ficer and Local Registrar ~,f ~ ' - r_, ' = n - . . - . _ . -'t7 , ` f ' o . ' _ ~ ~ ~ t - - ` j~~ • . > ~ . • I~+~w~ ~ t ~ ~C . ' . ~ _ ~ ~ - - De ty Locai R~gist r . : , - . . _ ~bQl( PACE~~~: . . •