HomeMy WebLinkAbout0955 ~ ~ ~ _ - ~
/ •
1~
(
f
1
i
,
.
. ,
` .
. ~ .
. ~
~ ~
~
~ ~
. ~
a~C~40 ~ .
S~ . ~
~
~ CERTIFICATE OF DEATH ~
~ocx ~?t Mo. 98 F L O R 1 D A
~ OECEOEHt-NAME fMSt M~OOtE LACt SEx OATE OF pEA1N~4o D~r v~ ~ r
, Jamee Thom S~tnon ~ta~Le ovenr6en 9, J 986 ~
6602 ~E-~9•~w~ Ma? AOE -LU18ut1W~y UMOER 1 YEAR UNOER 1 OAY DATE Of S~RiH~W O~?. COIiNIYOF DFATN
~ $S.RC~1~I?r/ S~ 7~r„~ ~ ~ o~rS ~ uR5 ~ uiHS anuan ~ S ~ 9 ~ 5 t~ SQ~.VI~ ~~lCi~.e .j
C1TY. TOYIM OII IpCAT1pN OF OEATN HOSPITl1~ OR OTHER INSil1U~lON-IWrM fll ~Wt /n ~tMr, p+» ftnal ~nC rwrnW.l li MOSP OR INST ~InAKata DOA ;
~ OP,EmH Nm.InpHynllSWt.~r/
~a .ien~
~e
SiATE Oi SIAiHIIInoI ~r C1T12EH pf MR/AT COUNTNY MARHiEO. NEYER MARHIEO. SURVIYIHG S~'OUSEl1/ od~ qn~ ma,Wn nrn~~ _
7A rYS A. n~nr cant.rl O` O,?v~j EO {SC~c=h~
• f.{. 9 U S ~ 1 Qn~{.QU tt
SOCIAt SECURiTV NUYBEH USUAL OCCUVATIOMl~~ ~y~ ~
~
nt~l KINp OF BU51NE5$ ON IHDUSTqv
264-03-39S9 La6onen ~b nua
RESWENCE-S?ATE COUNTY CITY, TONRI Op LOCATlOtI STREET AHQ NUNBER INSIpE GTV 1IM115
" ,w ~ ~.inz Luc~.e ~,phx P~.ence ~~06 G. Tennance ;w°S9'~S'°'"°'
~ fATNER-HMAE FIRST MIDpLE LAS~ MOTHER-W1pENNAYE fIRST MIDULE LAST
~ +s 7am b ~s
INfOfWANT-NWE (/rq W RuN) MAIIIN(? AOpAE55 STpEET OR K F 0 NO CITY Op TOWN STATE 11P i:
~ Men.d.i.t, S~xon ,~0 1506 G. Tennance Fox~ P~,ence F~on.ida 33450
Bll~itlLL,f,iiEMAlION,REAWYA~.OTHfRISpaalrl CEMETERYORCREA~ATpRY-NAYE IOCATtO.~! CITYORTOWN STATE
8un.~a Foh~ P.~ n C p -
~ fW~ERAI OR FUNERAL HOME / Z p v enu e D.
,k , ' P ' x . ~
~ ~ 2p~ T Da~ W my lnnwNOp~. tn occwna M n~ n+n~. Oaa anoy4c~ Mo ow i ti• On ~ne Cws M eirnmauon anb'w r~wstq~tan. ~n my oqrron aa~n xcurrca at t+» ~
. s cawNsl ~tw0 / j t~me. One u+0 W+ct rb O~+e b tne cawels) statM
~ (f~M~ W TrY) ~ ~~"1 K ~ rM TMM) ?
~ OATE SIGNEOIMO. Wr• Yr ) HOUR OF A DATE 518NE0 IYO. Day. Yr ) HOUR OF DEATN
O r
~ ~ ~ i i r 8 6 ~ 3 : Y~ ~,e ~
~ = NAYE OF ATTENOINCi PNY51C1AN If OTHER THAN CfATIFIER /~YD~ Oi Prrnfl =a VAOMOU?'ICEO OfAD li1b. O~y. Yr.J PRONOUNCEDDEADlMOwI
~ 306 ~ 210 ON 21~ AT A1
4 IiAlIE M!O AD01~55 O~ CERTIF~ER (iHY91C1AN. MEdCAI EXAMINER) f fypa p pmU
a
; n Dan k A nm p
~ REGISTRAR ~ 11 OATE NECEIVEO B1I REGI TMR~Rtn_ D~y. ri ~
' ~ ,s,,,,~,,,, ~ la ~dp No~v~rber 12 , 1986
N. MAE TE R ON1Y ONf CAtlSE~EA lfNf FOA/~/. (b). AND ltl I ~ i~N~nv D~[«N++ onsM ana destn
~
~ 6ii'1~L7. ~~%vw7' I -
ouE To.°~
ns Co?+SEO E o+ s) vdreh y~,r~ nw ~o ea+s~ W- liM u+dry.+p ca~ srq im.nlu e~t.een on,N ~ne oe.~n
e /dYQ.~,K. /~~P~w ~ ~ I
DUE TO. OH AS A CONSEOUENCE Of ` I InisrvY D~lrNn priM ~n0 dMh
u ~ ~
° i
IMRT OnER 51Rrd~K'/W T CaJ01T10~lS- Co~+dOO~r CaTAA~+p q Ma/+ O+t ~+at nyMO b C~e~ pw+ ~ fMT I W ~A~T 1~ F GE~IE W~.S iNfNE A ~UtOPSY CASE REfEfFEO TO 4fUCA:
¦ PNEG?tANf,ti' N ME VASt 7 YONT~6+ ~~es c, rol ErAYNEp m a rol
2n rw C No u ?S 26 _
V
tPrat~Wi) IlCGOEM. StNC+OE a W1TE OF IrM1FtY (MO . Dh. Vr ) ?~OUA Of iWURV OESCR~Sf HOw ~N.t~?A~ OCWRNEO
KowuDE.auHOEr~a~n~orsps.hi
HRS Fam 61t, m z~~ a~c ~ t~e
f1lJUqV AT WOqKfS,pOt/r iLACE O~ IMJUIIY-M ApM. I~rm. ~qNL I~tlOry~.Otbc~ IOCA?ION STI~ET OR q i O NO GTY CR TOYVN STA7E
Ui ~1 (Ob~0i~0~s Y~s or No) anwwg. Nc. fso.ahl
N~~ l7~ II1
a ~Y„a+
~ , r~wy o~tity ~hM to b~ • Mr~ ~ aonc~t aoP'y eF th~ ioc+~
, a.~ia..r. r~oord on fl~ a+ t~d. cax+W ?M~+ ~U~,.040 -
' m~m st Porf PIKa, f~id~.
(Waminq: Nd v~lid unl~q 1 ~ tM1 Of 1hr ~ Lydi
CpueMr Hsshh OM~pw~i
~ 1~-~aH~~1` • u i ' , , ~
: i 8 A1 i
:f~~~~~:Y ` ~5~
~ MOyfnr ~ ~ ~
: • n eT L -
~ ~f' UCit L
. 1 fr„~. .
n~ N rM
~0527 P~b~0953 ~