Palomino, Rose Ceraolo
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HRS Form 512,
Jan. 89 (Obsoletes
Previous Editions)
LOOAL FILl NO,
1. DECEDENT'S NAME (First, Middle, Last)
c;ERTlFICATE OF DEATH
,.,. · FLORIDA
7.
Februar 6 1910 Indiana lis, Indiana
9a. PLACE OF DEATH (Check only ona: see instructions on other sw)
HOSPITAL: [3tInpatient 0 ERlOutpatient 0 Do... ~: 0 Nursing Home 0 Residence OOther (Specify)
9c. FACILITY NAME (II not institution, give street and number) 9d. CITY, TOWN, OR LOCATION OF DEATH
2. SEX
Rose
3. ~TE OF DEATH (Month, Day. lIlar)
Palomino
NUMBER Sa. AGE.Last Bit1hday
(yaars19
263-22-3584 7
7. BIRTHPLACE (City and State or Foreign Country)
5b. UNDER 1 YEAR
Months Days
Female
5c. DER 1 Day
Hours Minutes
Januar 1 1990
8. DATE OF BIRTH (Month, Day. lIlar)
8. WAS DECEDENT EVER IN Us.
ARMED FORCES? (Ills or No)
No
9b. INSIDE CITY LIMITS? (Ills or ~
Yes
ge. COUNTY OF DEATH
9a.
9bde.
10. GIVE KINO OF
WORK OONE
DURING MOST
OF WORKING
LIFE. 00 NOT
USE RETIRED.
Clearwater Pinellas
11. MARITAL STATUS -Married, 12. SURVIVING SPOUSE (II wile, give maiden name)
Never Married, Widowed,
Divorced (Specify)
lOa. DECEDENT'S USUAL OCCUPATION
Pro rietor
13a, RESIDENCE - STATE
Retail roduce Widowed
13b. COUNTY 13c. CITY, TOWN, OR LOCATION
13d. STREElAND NUMBER
Florida
138. INSIDE CITY
LIMITS? ('rN or No)
Pinellas Clearwater
131. ZIP CODE 14, WAS DECEDENT OF HISPANIC OR HAITIAN ORIGIN?
(Specify No or ltI$ - "yas. speci/t. Haitian, Cuben,
Mexican, Puerto Rican, etc.) ~o 0 Yes
2707 Morningside Dr.
15. RACE - Ameriean Indian, 16. DECEDENT'S EDUCATION
Black, White, etc. (Specify only highast grade compler.
Specify:
Part II
28. CASE REPORTED
TO MEDICAL
EXAMINER?
(\lis or No)
No
3Ob. DATE OF SURGERY (Mo., Day, \liar)
ElemenlarylSeconda!X
(0.12) lu
~n Sumama)
CoIIege(I.4or5 +)
Specify:
Whit.e
18. ~'S NAME (Fltsl,:
"
Frances C. Leandri
20a. METHOD OF DISPOSITION
Ceraolo Rosa Versaggi
19b. MAILING ADDRESS (Street and Number or Rural Route Number, City or Town, State, Zip Code)
o Cremation 0 Removal 'rom State
1798 Lon Bow Lane Clearwater, FL 34624
20b. PLACE OF DISPOSITION (Name 01 cemetery, crematory, or 20c. LOCATION City or Town, Stale
other place)
Clearwater Cemeter
21b. LICENSE NUMBER 21c. NAME AND ADDRESS OF FACILITY
(01 Licensee)
Clearwater, Florida
/7r,L3
Rhodes & Wice, P.A., Funeral Directors
800 East Druid Ave. Clearwater FL 3461
te an~a and due to the
23a. On the basis of examination and/or investigation, in my opinion death occurred,
the time, date and place and due to the cause(s) and manner as staled.
S natu.. and Title ~
23b. DATE SIGNED (Mo., Day. Yr) 23c. HOUR OF DEATH
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238. PRONOUNCED DEAD (Hour)
4:41 A...
23d. PRONOUNCED DEAD (Mo., Day. Yr)
R (PHYSICIAN, MEDiCAl EXAMINER) (Type or Print)
Street Ste. 206-S, St. Petersburg, FL 33709
25b. LOCAL REGISTRAR - SIGNATURE 2Sc. DATE REGISTERED
~
26. PART. . E ter the diseases, injuries, or complications that caused lhe death. Do no! enter the mode 01 dying, such as cardiae or respiratory arrest, shock, or heart
'ai reo List only one cause on eaeh line.
Approximate Interval
Between Onset and
Dealh
Sequentially lisl conditions,
i' any, leading to immediate
cause. Enter UNDERLYING
CAUSE (Disease or injury
that initiated events
resulting In death) LAST.
Intracerebral Hemorrhage
a.
DUE 10 (OR AS A CONSEQUENCE OF):
Hypertension
b.
DUE 10 (OR AS A CONSEQUENCE OF):
c.
DUE 10 (OR AS A CONSEQUENCE OF):
d.
PART II. Other significant conditions contributing to death but not resulting in the
underlying cause given in Part I.
27a. WAS AN AUTOPSY
PERFORMED?
(Yes or No)
27b. WERE AUTOPSY FINDINGS
AVAILABLE PRIOR TO COMPLETION
OF CAUSE OF DEATH? (Yes or No)
29. IF FEMALE, WAS THERE A
PREGNANCY IN THE PAST
3 MONTHS? 0 YES 0 ~
31, PROBABLE MANNER OF
DEATH
No
3Oa. IF SURGERY IS MENTIONED IN PART I or II ENTER CONDITION FOR WHICH IT WAS PERFORMED.
32a. DATE OF INJURY
(Month, Day. lIlar)
32b. TIME OF
INJURY
32c. INJURY AT WORK?
(Yes or No)
32d. DESCRIBE HOW INJURY OCCURRED
(Specify) Aceident, suieide or
homicide; or undelermined.
M
32e. PLACE OF INJURY - At home, farm,
street, '8C1ory, etc. (Specify)
321. LOCATION (Street and Number or Rural Route Number, City or Town, State)