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HomeMy WebLinkAbout0297 , co::,~`- tTAT[ 60ARD OF Ht11LTt1 CER'fIFtCATE O~' AEATH ~~~f'j(~~ ~ ¦uR[l~u OF YiTAL ~'Tl1TIeT1Cg RAT[ FI1.[ HO.~ ~LQBIDA ord •e~n B N . . R p? o p~ ~ 11 1. ?iACi 0/ @4ATM COD [ NO. 2. FD'WAL A[fIB~11C[ ( IIMr 14wa~/ Awl_ 6wtls+i«: RwH~r ~dati ~Leiw) f~~teL~d ~Q aed •111 ° 1'lar~i~n ~3~027 `~~Y'~C~B b JL~'.T Lucie a. ylae•a la p~~- O- CITY• 10Y/N.OR IOCATqN c. IS ?LACE Of DEATH t. CIT1. TOWN,OR LOCATpM t. ti RESIOEliCE ate~et IMSIpE CITY IIMITSI IIt510E C(TY lIM1TS1 ~ rile. ~ttlsrt YESQ ~o? Ft. PierCe res ~a NAME OF (1/nol f+~ ?Mpifst, /ht i[rttl el~rta) f. STREET ADDIIES4 ~ HOSPITAL ON IRSTITUTpN ~rt~ Memorial Nos ital 170 Princees Dri~e (PSL) 3 IIAM[ O? Fbif l1fllllt ' l.~t! 1. DATE MenfA D~9 YtY ~:r~~`n ROB~RT LEF. TO'~.INSON ~TH December 196~ ~ ~ . SEX 6 CO1011 011 RACf ~ MARilFEO ~ NEVE~ MARIIIEO ? ~~TE Of tIRTH 9 AGE (/w tltl~ i li?r0E11 1 T[M ~ H~_ M~le White w~oowco? aro~ccu L18C. ~ 1a9$ b~ebt~•r~ xwa, sk.. K.,.. xr., i 11 r f c • ~ p 1 a f n 1 3 10~. USUA~ qCCU?ATION (OiOt tiRf oJ~oo~k [owe IOD KIMD OF ~USINESS OR INDUSTRY I1. ~IRTNPLACE (3t~lt n/O~tl/a totttllt/) 1. C~tt2.E~ OQ t~MT OOIAtlflYl ; ¦~h~nt•r ~+rfR~~~oNoJeeMRin{1~/t,nralJrdtrd) ~,0:1'10 VC 811d U.~A C" ~ Dlack 1nk FATM[R' NAME 11. MOTMER"S M~IDEN qAME I ot ~ ` t~Ps~rtter U avai able ~ ~ IS. WAS'DECEA$EO EVER tN U. S. A11MED FOi1CE5~ 16 SOCIAL SECURITY NO. 17. IM/1RIrA • NeMAT61R~ ~ ~ ( Pa. r. w ~rl~erw) ~.............k.., p.,:~~ ~ ~~~v Tomlin~~~~tl - -Or-~J78 A«~•, 1'~0 Princess . .~c`e~ ~ < Tun~ral I!. CAYbi M/ i8AT1t (fikl~~ nti/ m~r a~ pt? ll~u JM (a). (D). eR1 (r).) IKTERYAL iFTMtt1~ ~AIIt 1. DEATH MAS CAtlSEO ~Y~ AM DfA X ~ f 41~~eto~ IMYEOIATE CAUSf ACLktA 'fYocardia1 Infarction m~nU 89 ~u~t fil• - } er• e~r- Y881'9 f t~t~e~t. AS?-iD ~ ~ Clrs!{[Imu. i/dt. DU[ TO lb) - - - L fl~b ~hf Y'~~t~ /!N /lIf 10 - 1 O C • I ~Oft C6Ylt _ ~ 1 e 11 t r rl~lla~ ~?t r t11tr. OUf TO (t) s ~ •lthln ~9 fify c~rre fuf. i ?ART 11 Qt~i7! SKKf1GlR CaNflfilOtPS OON7~l~IJT1M 10 DLAT11 iUT MOT RItAtED i0 t/1E TLRY{Ni1L DtSEASE C.0llqiqN 6(Y[71 01 ?MT 1(0) . W A f \outs •f- ~ ?ERFdRME01 ~ d•~~b Hed Pacemaker in place fourteen months „E,p „oQ ~ = o~ O~fet• ~ 2pp pfSt~IN HQ1M I~+JURY OCCURRE~. (fitf~r ~~frrr ef Iw/rrj iA Pat /or Pol 11 ~J1fte~ It.) ` •~tin6 ACtIDEteT SUICIDE HOMKtOE i at+Po.~- p O s < <101! Ot ZQ[. TIME Of HOt1? ~O~If~. }~lp ~ ioaj. IIUURY . E D. R. ~ ~ 201. IMJUlIY OCYURRfO 7Dt. KACE Of IMJUII~ (e. M W oAoul ~ewt. 20J. CI7'Y. TO~N. OR LOCJITpl1 OOUIITY STAY[ € ~ YfMtLE AT ~ MOT MMFLE ~ /~~.l~~r. ~?~s~..~ie• dp., ~re.) s 1MOQK AT MONK r t ~ ~ 1~ft~nd~d th~ d~e~t~~d /tom ' . to ~nd l~~t ur ti~ ~tirs on ~ -~~t odovrr~ ~t ~1 rn on th~ d~b ~tst~d ~6o+s: ~nd to tAs ~~ae o! m~ knowNd/~. f~om fA~ wu~ ~b~~d. ~ ~11 f t~~s ..MNtAtY![ (Dyru a t4k) 22D. AODRESt lts. DAT[ it0lRO ~ D, J~nsen Beaeh, ~'loricja 12,/9/b5 ~ ~..oi.c. a R . Penick ~ .ceurae.! 2 2}a. ~uRUI. CMrAT I~D- pATE 23t N~ME OF CEM[T[RY O# Clt[MATOIIY Z3+t. LOCATqiI (Cff1.101n1. N t1YMf~I (~~Ml ~ 1ltrovu. (3pet1~1 n/l~7 ~ = : ~ 1, i ~ . y 1G ~ 10 ~ - ~ra~~~s~~~.we~.~s.4o.~~~ws~ Fulton Cou~t~ 8n j 8. / O1! j~. N '3 S16NATU RE 2S. DAT[ llECO. LOCAI REG. 26. R[a1STItAl1' ~ ~ate ~eral Home i~be Jaek J. I~oore trce F].orida Dac. 9 196~ Blancha~ ~'Iartin Lb t-