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~ CERTI~IED COPY p~~' ~
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~ h~reby cer~ify khe ett~ched to be a~rue and correct copy af
Local Reqistr~r's recorcl on ~llE in the ~row~r~ County Public
Nealth Unit in Margate, Floxida.--
i~ARNINGs ~Not valid unleae rafsed seal of the Broward County
Ptablic Health Uni+~ is affixed.
. 9;-29
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~ LOCAI illE H0.
~ DECEDEMT-NAME FIRST MiDDLE lASS SEX DATE OF DEA7H(MO. Day. n/
It*~'OEOOK .
~~,~,g . ~ SABRA LEF: BUSH z Female , Sept . 2S , 1986
~ AACE-a g, NTite. &uY A4E-LUt &nnGy UNDER l VEAR UNOER 1 DAV OATE Of BIRiH (MO. Oay. Yt) COUNTY OF DEATN
Am. IrWean. HC. (Spsuly) ' IYp.I ~ pAYS NOURS ~ MINS.
~ White 89 ~ x 6 Jan. 10, 1897 „ Broward
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CITY. TOVYN OR LOCATION OF OEATH HOSP1TAl OR OTNER INSTITUT104-Namelll nof in e~t4er, yrve strett aMnumpp: ~ iF H057 OR INST ~IrA~ute OOR.
:~e OP/Emlr. Rm . Inpat~tnt (SPK~1y/
' e~e.Wi1t0t1 Manors Manor Pines Convalescent Center ,d Ingatient
~ SiA1E Of BIRTHI~?~W i~ GTIZEN Of WHAT COUNTHV MARRIED. NEVER MARRIED. SllqVIVtNG SPOUSE111wds, yne maxfen nam~)
US A, rtsrty cau~fiy WIDOWED. OIVORCEO {Spsc~hl
J~ . s West Vir ~nia , USA ,o Widowed N/A
~ SOCUL SECURITY NUMBER USUAL OCCUPATION ~Grvs ~~nd of worA done dur~n9 K!ND OF BUSiNESS OR IkDUSTRY
~ HOl18EW'ff@4~n9~re.we~~~,er,~ea~ Owr? home
~ 17 233-52-4126 _
~ HES~DENCE-STATE CWNTY CITY. TOWN OA IOCATIOt! STREET AND NUhIBEA 1NS~DE CITV UMITS
4 (Spfat~ Y!! O~ NO)
~ G t4a Florida Broward ,k Wilton Manors 212 N.E. 29th Strest Yes
~ `~0~~ FATHfR-NwA,tE FIAST MID'JlE LAST MOTHER-MA~DENNAME FIRST M~ODLE lAST
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~ ,S William Brosius Floreed Roach
~ INFOWA/tNT-NAME(lype o~ Pr~M~ 6tAILIN(3 AODRESS STREET OR R F D. NO. CITV OR TOWN STATE DP
tiazvin Bush 525 N.E. 27th Street, Wil~on Manors, Fla. 33334
• BURIAL. CREMATION. REMOVAL. OTNERISpec~ly/ CEMEIERY OR CREMATORY-NAME IOCAT10rJ CITY OA TOWN SiATE
Burial Forest Lawn Central Far~ Lauderdale, F'lorida
• F LDlfi£Ci0 S n~re a/ • FUNERAINOME ADDRE55 2505 N. D~X1~ HWy.
,go Kalis F~neral Home, F't. Lauderaale, Fla. 33305
~ = i0a To 1 b~et ot my t eeatn occu~~ed u i brt+a. Oate and p~xfl and due Q 2U Ort SAe basis ol ezami~at~on eM~or ~nvestys!ron, m my pp~n~on deatn occurre0 st tne ~
_ olrieu~rse(s)auted- ~ ' tK++e. da!e ~M Dia;e snd due to the ca~vfs) st~ted i
' ~s ax. ana rzw) ~ ~ • Dy_? ' $ = l~+ynnu~ .na sm.) ? !
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' OATE S14kf0(MO. Oay. i) HOUR OF DEATrI OATE SIGNED l~o. Oiy. V~.) HOUR OF DEATM
u
9--26-Sfi 11:05 A M u~i z,o t~c M
~ E~ NIUIE Of ATTENOIHG PMYSICIAN IF OTNEH THAN CERTiFlEH (7yp1 d Onnl) E~ PHONOUNCEO OEAD ~Mo. Day. Yi.) PRONOl1NCEDOEAOiHOUN
~qa Fj
p pd ~ 21d ON 21e. AT IA
NAME ANO A~ORESS OF CERTIf If R ~CMYSICUH. ME01CAl EXAMINEN) f iypl a p~inf) ~
?2 Daniel C. Smith, MeD., 1930 N.E. 47~h St., Ft. Lauderdale, Fla.
R£a1STRAR OATE RECEIYED BY PEGISTRAA/Mu. Dey. Yi.)
J 5ub-Re 9~26-86 23o S E P 2 6 1986 C+'
a3ersp~,~w.r? , . L` g• Ci
21 fM/AEDiATECAUSE (ENIEROHLYONECA(JSEPERlINEfORfal.l6}.ANDlc1 ~ Ilnterratbet«te~onsrtancfdeatn~
'~"'T Cexebral vascular accident ~ 2~S months ~ ti
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~f DUE TO. OR IS A CONSEOUENCE Of iCaidNO~(t) wfiiCh paeO risa to tattse (a) - lisf underl~v~ tause tasi) ~~•e~N DCtw(!~ O~5l1 dn0 0lat~~
~b, Cerebral axteriosolerosis ; Years ~
~ Irtterral Defween pnset anQ dest~
WE TO.OR AS A CONSEOUEf+CE OF~
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4 _~~1 ~q~
~ /AAT OT11ER S~G.N!fl(;AfIT CCY.'qTqN$- Cprricony cMrbJr+q ~o a~ [ad nd ~d.r.cd to v~se prt+i n VART 1(a) iMi W IF ifMAtf. WAS (!!fHE F ~U10GSV C~SE RE~ENkEU f0 NEl7CF1 ~~i
-'t ~ PP.EGNAt~ICY PI~~f ~I51 J MONf~tS~ ~O rtiy :c,V,+.•:Eit~ccrry res n ~e) ~
Yes N i NO
(~ro0aMr1 ACCIpENi.5UIC1p£ a nATE OP INJUt?Y (Rto-• Day. Y!.) ~iOUR Oi INJURY DESCRiBE HOW IHJVRY OCCURAEO .
~ ~ tiOMlCiOE. a UNDETERrtINEDfSpu/r/ ~ ~
17a 2~b 27c M 2IC.
~WT 5~2• INNi1Y AT YYORK{Sp~cdy PIACE Of INJUHY-At nom~.larm. tlrcet.lxlay. dtKe LOCAiION - STR£F.T OR N F.O. NO. GTY Ofl TOtM1N STATE
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