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~ CERTIFICA7E OF DEATF
FLORIDA
LOCAI Fl1.[ NO.
::~CEC~EN?--NA?aE FtRST ~ MiDDtE B10 m Srtale oSC[1CC'MhE'T <<, Y1Q~7 ~
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G? .i.E--e g tYhde. [i+xk A3E-last D~nAOjy _ UNQEFI 1 YFAfi__ UNDER 1 DAY _ OAiE Of 81RTH (nw. Wy. Yi.) COUNTY OF UEAI'H
Am ~r~~~~
~c (Spotdr) (~'~s ) MOS OAYS HOURS M{NS BTOW3TC~
a ~ s~ 82 w. x 6. Oct. S, 1904 ,a
~ C~TV. TOWt{ OR LOCA110i~ Of DEA7M HOSPITAL OR OTHER INSTITU7lON N~me (d not in eif7~"r. yno sLebt and numDe~) If HOSP OR INSi~tn<llate GJA
Of'/Emur Rm in;,~t~en,Sprc,fy)
Pembroke Pines ~~.Pembroke Pines Hospital ,e In ap tient _
5* a7 E OF QSR1H ~!I nof u~ ~ G~71ZEN OF YfHAT COUNTRY MMRItD. NEVER 1.lMfUEO. SURVIVtNa SPQUSE (X wo-b, giva rr.anfM r. vrte)
U S A nonre covntry) 100YYED. DNORCEO (SpecJy)
~ a New York USA ,o. Married ,~MoZly Serota
uc,~:i~~ SECUR~TY 1:UM~JER USUAI OCCUPATION ((3~vs Aintld +raJr da+e dong KtNO OF (iUSINESS OR WOUSTRY ~YAS OECfDt?'Jl
EVERiN
most of M~akYg Lio. ere~f 7 re6red.) t1.S AR.VED SER~'~:;ES
113-20-030G ,a,.Certifiec~ Public Accour;tant ex. Aecountin vesor+oc~
~'K i1~~~DEttC[-STA7E COUNTY CITY. TOWN OA IOCATION STREET ANO tJUMBER ~~708 1NS~t3E
CItY UM!1S
~SpocAy /"os a l:o)
,a,Florida ,<e Broward Pembroke Pines ,.e.811 S. Holl brook Dr. Yes
FA7nEF~-NM,tE FIRST 1JiDOlE LAST IaOTHEfl-NAME FIRST Mt06LE tdafOEN C)
~ , 5 David Bloom ,e. Esther Jenechovs__k~r__~
I t+lFOR\1AtJi-NAME (lypo M Pnnt) MIUl1MG AOORESS STREfT OR A F.D. NO. CtTY OR TOWN STATE Z~A
;iichael Bloom ,n, 336 Poinciana Island Dr. , Miami, Fla. 33160
c;~~R~n~, CRE6IATWN, RE?40VA1, O(HER (Spcc?y) CEMETEAY OR CREMATORY-NA~,tE LOCAf1~Jl~ CiTY OFt TOW~J STA1E a'=
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- te, Burial ,e~ Lakeside Memorial Park ,e~_ Mtami, Florida •
FUItFItAI D cror~--s~~r~~ fUNERAt 110ME Riverside rsemorial Ch~
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~ ~ ,~,16480 N.E. 19 Avenu~, North Miami Beach, rl . 33I_62
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my krtowleelgo. 6oat occurr at i?+s tmo, dato and {~I.ico 21a. On lh6 baSiS ol Oiarten~[Wn 8lidior +Meslg~:o~. my op~r.rpre dcarn occtxrni ~t
cHw ~o ua cau.a(s) swWfj~ r)l JF ' tne Gme. date ~n6 P~ and dua to tne wuso(s) staced
(SlynNwt arM titbl? J~i -fC~ t~ ~-G•L /l.~~C7 1s~9^ahx~ Md Tltle)?
OATE Slu?JFO (4~0., Wy, Ye)~ HOUA OF pEY1TH DA7E SIGNED (tlo. Qay. Ye1 HOl1R OF OEAiIi ~
~ob~lr~~ 2oc. 9:10 AI~i ~n 2~e. 2ec.
NAla[ OF~ ATT[NDtNG PkfYS1C~AN tF OTHER TttM1 CERTIFlEA (J~pe o~ Pr.r.q PA01fOU~~CEO DEAD ~Mu , Day. Yr.) HONOJNCEO DEAO (Hau~/
21d. CN 21y. AT ~
; ~ rrAME Ahp nD()RE55 OF CEHIIFIEfi IF'?1YStC~N, idED~CAL E)eAMtNE ype or Pr+nr) / .7 e
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~ NcG!iIH1R ~ jj / DATERECE~VEdBYREGIS7it1tR(Mo..Uay.Yt)
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~a.,:s~~a~~?_~~%w~*-'> . e.... sub/reg. Sept. 9, 1987 SEP 1~ 1~~._~ ~
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Ihl~1EOtAfE CAUSE (F,/lTER OfYtY CAllSE PfR UNE FOR (e). (b1. RNO tc1/ Ntterval oon onse~ and dea!n
PART (a) - >YrL-~C~s•~-~ (r Ci''J~/(.--~~" ~ ~~~~L~[~
~ _ t- ..~c~.. C= ~
DUE Tp, Ofi A$ A GO iSEQUE:4CE OF (Cax4t~on(s) which gavp to tause (aj - List underlyWx~ tause tas~i Interrat bMwEen onset ar}d dea'A
m~ Lj . ''5~.~~"?"L!C'~c ,P-~-Y ~'`'Q~ C- -f~~/>
~ CVF i0. OT1 aS A COtJSEOVENCE OF ln al GeMeen onset a:h: Gea'
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~ ~.~''%`t% 'i,~ ~..fL~l~~ h~~~~ ~j~~-~'~6~j
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P~rt V iNER S~GNIFtCANT CO~dDiT10NS-CondRanS conl to doathgot nal relate0 lo tause PAR fp tF FE WA$ T~4ERE AUTOPSY GASE REfEHREO TO MEBtC/LL ~
1! g~ven m P~n i 1(a) '~J " • A PHEl3NANCIEIN THE PAST 3 (yos a rto) EXAMINER(Spocdy yes a r~)
);1~~, •%-.{t/Jt~yZ~c ~..G~ Ltt~~fLl.•t ~2~LE-t~~C-4( ~or+rHS~r~sO No0 n no 26 no C9
~F SUi:C~RY MENTtOt1ED ~N P 11 a 11 ENTER COkDfTION iOR 'H R WJ1S PERFOR6IED OATE OF SUFIGERY(1.{o, Oay, Yr1 ~
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_ Z~a 27b "9 ~
i~'rcbaD~y) ACCIOENT. SUtGtOE or DATE OP N~1L~AY (Mo, Day. Yr) MOUR OF tN,lUftY OESCR~E3E~Y11;~GHy , _ , -;'r'_ • ~ : ' . _ . ' ~ '
tiOLt!GtbE ot UNDEIEAAIINED/Spec~Y1 ~ i/ h.'_.~. ~
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i!:;1!RY AT Y10RK (SpeCt7y PiACE Of Ifi.iURY-/lt fwrt19. hrm. Weef, txtOry. DN,cA LOCATiON SIHEET OR R.F . kO ~GI ' N STAiE
Yes or ~fo) Lu~d+~g, elt. (Soacdrj . ~ - . ~
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- - .r"~t`~ CERTiFtED COPY - - ~
CT 2 0 198? • , , . ~
~ THIS IS A CERTIffEO TRUE AND CQRRECT COPY OF THE OFFlCIAL RECORD ON FILE IN TNIS OFFICE • ;r
. ;1
~ ~ tHE ST~T~ " " ~ ~ ~ ~ OUVER H. BOORDE ~ ~
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: ~,<y w 8 , State Registrar
~ ' • o ~ ~ Office of Vital Statistics ;
Y , p ANY REPROOt1GT10N OF THS OOCUMENT IS ~HHOhM81TED 8~ LAW. DO kOi ~ r
u WARNlNG• ACCfPT UNLESS ON $ECLZIITY oAVEH VYfTH EM~OSSED aREAT $E1l! OF iNE STATE
O~ fIORtDA. Al7ERATION OR fflASURE V07D5 THI$ CfRTIFtCATION
h~~D AE SF~~ . _ . . _ . . . . .
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MRS Fprm 1y6.{ 11;97)
RFCORD VEAIFIEU
~ f ~~-~n PALM BEACN ~(%i~NTY. FI.A
5~1~ J JONN E3 C" itJKLF
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