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OFFICE of VITAL STATISTICS
CERTIFICATE OF DEATH
~~E~~ JG~S FLORiOA
QECEOENT-NAMtE FIftST Mt1001E LAST SEX ~ATE Of DEATH fAb Oy 1'i)
5 , Forrest G. Ashmead, Jr. ~Nlale cember 19,1987
F~CE--~ q 1M~wu. B~ack A(3E-LUi BwttWar __UNOER 1 YE,Aq UNOEii t DA1I _ OATE OF &RTM (mo O~r Yi i COllNTY Of OEATH
~~a~+.k tswWr~ rr~.~ 30 1i1OS a?rs nouRS ~s Jan 20, 1957
4 White s~ ~ x e. ~YY Duval
Ci
TY. tOWN OR IOCATION OF DEATH H03PITAl OR OTHER INSTITUTION Kam~ (I +~W n rdir. piw an'rM ~ntl nun~bM IF M05P OR INST(IM1ca1~ DO~A
OP1Ertw. R+n fnDatw+l(Spt~!)
~ Jacksonville 7944 Cecil Street Ta
STATE OF &R7Ti not n CITIZEN QF WHAT CpUNTRY YARRfEO. NEVER MtAAR~EO. SOOUSE (N w/r. 9M nri0rn i~amel
D. dVOfiCED fSptl~'1
~'~.or'id`~"~a`~"' 9 USA ~o. N~'ried Martha French
SOCUI SECURSTY NuMBER USUAI OCCUPATION (Gn+ bd d rak dan~ ~rsi9 K1i~10 OF BUSU+ESS OR U~lDUSTRY wnS oEGEQfN! £vEA !N
maw a~.+~r r.. .rw~ ...trw ) .orei Tire us_ Aat~EO sERVICEs
,Z 262-80-8608 Distsi.butian Center Manager ; 'rts o "o
REStDENCE--STATE COUNTY CI?Y. TOINM OR IOCATION STREE? ANO kUMBER W~iDE LN?
(Spscly Yu a Mvf
taa ~ t4b. 1fc. l+d ~ie.
FAr~;ER-NAME f!RST tiMDOIE U4ST MOTMER-t~IM1E F1RST M~DOLE t~lAIDEN
t 5 te- •
, tNFOp4AN7-HAME (typ or Ao?1 MAiIWG STRfET Op R.i D. NO. C(TY OR TOWN STATE DP
't7 1 17a. ' .
URIAL. CREMATION, flEMOVAL. OTHER (Sp~clY1 CEMETERY OR CA~MATORtr-NAME L TION GTV OR TOiVN TATE
18a tEb. 1
FJNERAI DIREC - S~pnaAr~ ~11~~ ~~E t',~~„ l~]a...,,.
~ 17i1iLK~~ • ~.A.~G11.7
19a r v 19b. ~
20r. To Wrt d my k . d~atl+ oaw~W at the tims. Cate arW pw ard 21a On 1M Cani d n acou~nd at
eu~ m ur causMs) tt» tlrn~. date ane p4n tir '
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o~Te s~?~ I~w. o.?: r.~ ?+ouA oF o~?ni DATE S1GNE0 (Ab.. Uep. ri.~ °~PProx
M ~ecember 20 I987 z~~. M
NAA1E OF ATTENDIH(3 PMV$~CUW IF OTHER THAN CERTIFlEN (Typ~ a~x/ PROMOIlNCED DEi1D (~k?-• Oq: Yi 1 ~~+~1
j ~ 21~. AT
'i wWE ANO AODRESS OF GERi1F~ER (PHYS~CIAN, ilEWC1?l £XAM?NER) (TyP~ a? Pmtl 210 0 Jef f erson Street
Peter Lipkovic, M. D.
~ i 7 A~ r 3.,22 0 6 -
REGISTRAR - A RE(1J~ED EY ~1'~1
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23a (S+pn~?~wrl? ~
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t IM~MEDU?TE CAUSE (FN1ER OARY ONE CAUSE PfR LtlVE FOR (+J. 1 /c1I Y WtrwM+ an0 dwlh
i
PART (a~ Gunshot wound of ~ head
OUE TQ. OR AS A CONSEOlJEHCE OF (CaW~eo~+(s~ wAch gaw nse a cs~+se fal - tat w~0e~sp*q caua~ tastl Inarval Ostwwn oruw and d~sW
~ ~D)
QUE TO. Op AS A CONSEQuENCE OF NwtvN bslrwrn onsN nfd dsYh
w
(c)
PM OTttER StGNeF1CANT GOND~~'f0l1S--Ca+C~cons ~y+9 b s~ssn out not ruteled b pMT BI Ii FENALE WAS TYtERE AUTOPSY CASE REFERNED TO IytE~1"..J1L
tl gtien ui CAA7 1(i) A PFEGMANCYn~ 7HE PAST ~ ~yse or no) EXAWNEWSpsc~11' YM a no1
~ w~orcrKS+ r.s C7 rw O z,. Y2S 2s.
~F SURGERY IS MENTIONED 1N PAAT 1 Ot N EN ~ fON FOfi N?!ICM R WAS PEAFORAtEO ~T~ Y~j
- Z~a
iP~o~aW~ A~CC~OENT. SUICIDE a OATE Of INJUfiY (4b.. D+Y. Yr.) HOUR Of tNJURV OESCAIBE FIOW IWUAY OCCURf~ED
kO~A~CIQE or UNOfTEHN~NEO (Sp~clY)
Suicide ~kec.19,1987 ze~3:30 pM. Shot with gun
!W1/aY AT MtORK (SOk+h' PLACE Of Nr,iURY-J1t Aa~a, fann. fUaM. +aceaY. oNCe C@C ~~~~0. G7Y OR TOWN STATE
Yp a No) ~+4~ ~ fS0~Y1 .
~ ivo riome ~~acksanville, FL
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~a~ 2 1 1~ CERTIFIED COPY
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~ - SHIS 1S A CEATif1E0 TAUE AND CORAECT COPY OF TNE OFFICIAL REGORD FILE IN THIS OFFICE
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€ tt ' ~f St~E St~rP ~ ! i(~A>id~~ LIVER H. BOORDE
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~ u WARNit+IG~ ACGEP'i UNLESS ON 9EGtR~TY ~AAER WITH EM~OSSED OREAT SEAI OF T1f STATE ~ -
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