John P. Kuhnt.• I ffc'` �� \/� \\f 9s �' lr., I C~�.: r'y 3 Y'i+" ` n`. \C'A rT4T \..\. i \ i 1�
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rERA6wENr CFiT(FICAT� OF DEATH
K K--�idULFaENoi FLORIDA / \ \
OFCEOENT S NAM \ \ - \
\ FIRST. ` UST \
SEX
3 DATE OF DEATH(Momh Day *ji) P:
441
,
! SOCIALSECUPITY NUMBER `b AOEtasl Brill
\ :March 24-1998 ' (Yds s/ „ aY bb. UNDER 1NEAR / ,bc-UNDER 1 Ody
507 20 7564 74 MonIns 1 pays ' ; .Hous M nous
6.,OATE OF BIRTH (A/onfh Ory 14uj': ' 7. 81gTHPUCE(Crryand S(afe, or foretyn CouN
7QCtober"2�<1923 / 'Y) 6 WAS DECEDENT EVER INUS
ARMEDFO CES
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\ �HOSPITAL ' .
1� ' \` -9C-INSIDE CITY LIMITS7(Wsa�Lo)
�:In(!ai e 1 ERYOu(pauem WA OTHER. Nua�ng Home jiesidunce Rhe}� S /' \ > `
Bc. FACILITY NAME /(no(msf t frm, Y (Pa<XYl . �'eS
960e ( 9n'e Nmol and mWJ. '
/ c 99`GTY TOY/N OR LOCATION OFPEATH 9e. COUNTY DEDEATry
Leesbur Re ions Medioal Center` `
Leesbur l La e
Iq. GrvE Kwo OF IOa. DECEDENT S USUAL OCCUPATION fOb, KIND OF BUSINESSRNDUSTRy II MARITAL STATUS2. URVIVING SPOUSE I WAe,
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y pUaNGMOsr - Neye Ma I d9Wgd 1" V-1 deo namet
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LIFE W IIOi \
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13 13a.RESIDENCE-STATE 13bCOUNTY / f3cgTY,T()<VN,ORLQCATION IVfa Ann Miller /
13d STREET AND N(IMBER
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Florida Lake } j, Leesburg
13e.wsioeclTv 9705 N(oko Hollow Road Lot �#7(j
LIMITS7(tbuu o) j,31 YIP CODE.' l! WAS DECEDEN t OFHISPANiCORHAITIACNO(iIGINt
\ / puc fY Poo )tis—/I z,s{wcdYNrc ban IS BacE Vm lie eekaR indnh, I�.'DECEDENT EDUCATION
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N 34788 Pocdy En^enaovar .moo fas..l<.,
17.FATHERSNAmE(FusL Mddb L iQ\ ( N 12+ \
f 18. MOTHER'S NAME (f tf Midd/o. MagJon SJmamaj
/ a Johne
�! 19a. INFORMANT S NAME(/ypoYP q \, Unobtainable
/ ( 14b MAILING ADDRESS IS((oaf andNunWer ork rpf Rovf N moor 'y State, Twv Sfaf&Z.p Code)
\ Mrs. Ma Ann Kuhn
20a 20a METHOD OF DISPOSITION 'HOIIn-- W ROaL� I
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\ e 2ta SIGNATURE OFFUNERALSERVICEIICENSEEOR, 2ID'LICENSENUMBER; 2Ic.NAMEANDADDRESSOFFACIUTY�Sbur Flonda ;
PRS N Cf1NG AS S .. dire
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\ \\ 22a.'To In boils my kn0wtody. , d It '0 al Ih 1.
medal d pac nA to Ihe` ¢. 23a- On (no, basis d eaaminalKxl anNor oil at on ,in m
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datum and Tllie ► / �'w Ine Iirr), dale a W Y OPlnao death acv red at I
) ¢ pd place and des, to lha causes) grid manndr as slated
i X226.D ESIGNE ( m� S19-t're'and T16I I•-�
I r HOUR OF ATH i / E 23b DATE S)GNED(Mo Q Yr
Cj0 ���, Y 7 23c HOUROF PEAT
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B 22d. NAME OF ATT NDIN PhYSICiAN FOTH M Le L�
\ ( ¢ ( ER THAN CERTIFIER (Type
MEDICAL EXAMINER S CASE a
'24. NAME AND ADDRESS OF CERY(FIER(PHVSICIAN,MED)GIEXAMINER)(Type
3 `Humberto Delg�do;'MD 6p1�. DizieAJenue 'Leesbur Florida 34y48
�25a SUBREGIS7RAR-$IGNATUE AND QATEREGISTRAR —
SIG TORE
DATEREGISTERED
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THIS IS A �ERTIFIEb TRUE AND�CORRECTCOPYOF'TIIE QFPICI'AL REGARD ON FILE IN THIS OFFICE _
r� :AUC 1999
' . \; 4.• State F#egistrar
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