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HomeMy WebLinkAbout0680 j rh~+ be- ~TAT[ BOARb ot Hcn~rH CERTIFICATE OF' DEATH lt6~l rec- `UR[AU OF Vt7Al tTATifCT1C/ F L O R I D A ~T~TE Flli NO. _--r ord •hcn ' 01 TH NO. REGISTpAR•B NO.~`9 properlr 1 PLAG[ pP D[ATN COD[ NO. 2. Y1YAl R[~lOiNCt(~i~..~f~reuilt.~rl l/w~.twt.~w' Rs~<+NWw~~ww) QiltUtNd f COUNTY • STATf COUMTY and •tll ~Ol~e~~ '~(~,ol~ ~lt• ~~I~~ D• pl~ead ln Ql?- C1TV. TOWN.OR IOCATV)!1 [~S iL~CE Oi OE~TH t. C~TY, TOY.'N.011 LOCATpN t. IS IIES~DfNCf •snant ih51DE CITY LILi1T5) I?tSIpE CI1Y LIlIIT51 r~l.. Dt torili ~~Ch res[3 ~+00 tolsa 1 C YES~ ~a? MAME Of net in ~o~pitd. Qut ltrttf slfrt~ll ~ LENGTN Of I. STNEET ADDRESS ON A fARMI MOS6ITAL OR `sTAY ~N 1A Q YES D 1q ~ iNST~TUT~ON ~li=~~ H~op~t81 ~p rr _ _~~1~Q__fi 3 MAM[ O/ V f'Ir~( .IJ~~!!t L°•t d DATE 1~fOtel! Il~/ }'tt~ otcu?ua p(ATH ~~a t,+~~> >lfrsda H. M 11 s ~T .~9 9 S SE% . S COIQA Oll R~CE ~ MARRIED NEVEN MARIIIEO? a DATf O~ •tNTM 9 AG[ (/n fto~t ~~R t iEJUe ~pE~=1 NK lat! A~itA(~?~ XwW Mr H~rn Yic. r't c e t~~le COlOTIIQ wioovreo0 avoacco A ril 10 1 11 ~ ' p 1~ 1 ~ 1) ~~,j USU~L OCCUP~TqM 1(:itt kiad ef t ork dOnt I~D KtMDOF 6US1riE5500. tNDUS~RY 11 t;MTM9i~1(4 1 Vett T Jortyn touwlrl) it t1T1ZEX OF `1rMdT CWNTAT~ ~ , •it1~ p~r- lrri~yn~aloJtrorktnpl~J~.rrrn~/rtfirrl) ` ~ ••~Q~~ How~ ~rite Ha'e lt ~ . D1~Ck Inft ~ATMER 5 NAME 1~ MOTMEII S MAID(N XA~7( t t eyp..~~eo. Ptt~r Youag U~knotrn t ~ IS~ W~S DECE~SED EVER IM U 5 AqYED FORCES' 16 SOCIAL SECURITY NO 17 IM~ORMA S StaMATYR[ T ~ tir ` ~n~ w i - IYa. ~e, r r~lMrw~ ~l/ Ms. /.M tir s dat+~ ~I s..+wi - - ~.s,.~, 2.2 P i ni 8.t . D t ona aac Fun~ral ~0 CAUK 0/ O;AT/i ~ER/l~ O~II?O~f f~Yi! yLIIIY~f (o). ~A~. onI tr~ ~ IMTEIIVAL ~ETWEEN llRTt OEATNW~StAl15f0lY- \ M 01tSE7AMpDEATH ' dlt~GtO~ IMMEDUTE CAUSE _ !~~~X~~~ClI~O~ V.L~T~~ . . ~ - ' ~ ~ ' •u~t flle - - ' th• eer- ~ ttftcatc Coaduioni.i/an/. DuE To (G) O~nerali~sd ~eLa~ta~i~ •!th tAe r~itA par~ r~i`al~ • _ _ _ - - - - - ~ 1 o e ~ 1 eDw~ couee ~ . r~6litr~r t/dirt~ !~t undrr• - - - - - - - ~ F lrinp ~uu~t tat Ot,f TO -~`---'-~r - • i~ h 1 f1 7Z pAR7 ~I OfNfR SYMIFiCAMt COhaT1~S Cd~R:M~~ 70 IXIiH R1~ N0~ REVhO TO (HC TFIIti~NAl ~tSUSi. COw'O~~~ON GM~I ~1 MA~ W~$ AUTOPSY ~ hou~s •t- F , .ISAJ..~. ,.v i . :?ERF011MED~ . c.r ae,tn . ~ ' • "ri3? ?~oD ~ or before 4, ~~V~ - ~ j~la 20A ~ESCRilE NOW iNJURV OCCURRFD rF:nfrr wdurr ol~n~ur~ ia-1'er( lu Ptrt 0/kte~ ~f-1 ~ ¦aktn6 •n~ ~ ~CCfDENT SU~[~DE HOHK!CY . ~ , . _ 3 ~ t1~Po~t- U ? ? ? ; _ •.f' ' _ _ , " 1on of - - - - --'~---i~---- - - - - 24c TIME OF i/our ,lfonr~. Da~. Yrcr ' ~ oodJ. v irUUar a. ra. . i ~ p. rn . : . . . : • ~ ~ - • •'f ' STATE ° ~ 20d IHIURV OCIUaREO 20t PI~CE OF iN1U11Y ft. 0. ~R or o~out AORSt. 20J CITY. TOtYX. OR LOCAiqX COQ~1111~ , tVN~LE AT NOi VYMtIE la~~n. /a~for~. ~h«f. oJ,Sc~ dld~ . Uc.1 • ' z _ ; ~ ? ' ? . R T RK ~ r WO K !1 WO 21 I ~tto~ded th~ d~ceeisd l~o~m~ ~ . . to . ~ Z. •nd l~~t uw~ ~~fire on ~ D~~th occuri~d at __Z±-_-----~__ m on th~ d~t~ af~f~d ~bor~: and ro th~ b~~r oJ m) Rnorl~d(~. lrom tAs c~ut~i ~Nt~d ~ •11 ite~• jj~ f10MATYRt (IXprtto~lUftl 22h ADDRESS 22e. DATESIGNEO ` •r• to be E ~ ~o.p?.« . rp. L, J.nui s l1 D D tona Dsack? 5 z6 S9 aeeurate. 23a BVR~~~. C~Er~itpr~ 23A pATE 23c M4wE OF CfMETERY OR CR[MATORY 23t IOCATIph (Glt/, 7Wrlf. O~ t0eql~) (S7~lt) _ rOtr~ f 1 nJ~~ ~ar~a~` iia~r 1959 sunsst Pork D tons lN,ab t ~ S. ~ f412 j{ fUNFRl1l OIRECTOR 5 SIGNATURE AODRESS 25 D~~E RECD YY LOC~I NEG 26. REG~STRAR-S SIGMATURE 5 R~~.1956 S~rb~rt 4'hos~p~on D~yi?tona ~~cb S-2&-~9 ~rlins C. Minsr - Dep. ~ i ~ ( . r-. r - - - ' ' " ~ ~ ~ ~ ~ t ttQCOta R ~ O 0 tc - • - f ~ ~ t i ~ ; ' ~ 6 I r r.f ~ ~ P~~I 2 : 3 9 - . . . . ~ , , . - ~ c;~-,. ~ i f ~ ` `~"~v~.~c~~`F~ , { 1_.~ti~ C~~ ; Q~ ~°Q~ ~ ~ , - - , ' . - ` . ~ ; ~ o . _ ~ a ~ ft{:~~i`.,. . _ . . i':'.:~. ~_~L_r~Yl{ ° ~ _ t S i. L'UCl: C~.:Ut•: i Y, • c- ; ' h~e~b~ c~t,c ~ ` o~ #he L.~cQ,~ _ V , ~ ~ o,~#h~.e bc a~.cc~ c~~d exac,t cvp~ R~~~ c.: F p ~ OR ~ .Ll'l .t11.~ O~{l.Ct. , i ` y l ~ _ _ ~ ~ ,~~~d ~ ! d~ ~ ~ ~Not va.Ci,d wi.C~.~ #h~ ~~a.l o~ :Eh~ Va.~w.i.a Cgun.t.~ l~ea~L#lt De~pa~~i~c~ruE''~.~s"~I : } k ~ ~ ~ > >~Z~ ~ _ f D~.t~ o~c-3adS-Rcg.~.~.t~ca.c ~ooK 13~ -