Storbeck, Harold William
':;.;
'. ,
.~_Ilt or H..aitb and R..hahiJttallv"';;"rvi.....
, DIVISION Of HEALTlI
N ..-...- ""AL"'A~
CERTIFICATE OF DEATH
FL,ORIDJ\
STATa "ILK NO,
'II$T
MIDDU
LAn
"
RIrGISTRAR'. NO,
DATE Of DEATH 1.0,..'.... 0..... YI"'II
DEaASEO NAAAE
Hale
J. July 9, 1974
COUNTY Of DEATH
71 Pinella&
RACE' WMlfI. ~IOIO. AMI.tC.... INDI.....,
nc. t $nClfT, ~ i1... . J.
4, ;,dll,e
CITY, TOWN, OR lcY..ATlON Of DEATH
" Lar 0 k Yes
STArt Of BIRTH '" NO' 'N ",),... N'M' CITIZEN Of WHAT COUNTRY
COUNfrf' I
, Iowa
SOCI.tJ. SECURITY NUMBER
7.. 912 9th Avenue S. W.
MARRIED. NEVER MARRIED. SURVIVING SPOUSE 'If w''', GIVI _lOIN _ I
WIDOWeo, DIVORCED (SHe'N I
, US.'i..1i II Uidovred 11.
USUAL OC:CUPATlON ,G'Y' r 'NO O. WO.. DON' OU"NG MOST O' KIND OF IlUSINESS 011 INDUSTRY
W(MIUNQ LIP!. m... " 'fTI'm I
130, Bus Drj_ver
CITY, TOWN, OR lOCATION
It h 78 -14-:-6441
RESIDENCE - S T A 7E
140, floriCia
FATHER-NAME
LAST
S.H.
COUNTY
II~, Finellas
14<
Iarrro
lid,
MOTHER MAIDEN N"'ME
....'
"1"
MIDDl!
16,
MAILING ADURESS
'" l609-South 14th Street-Richmond, Indiana-tl73 74
:cIargueri te
Bayless
IS,
I NFORMANT NAME
vTilliam
F.
17. T"rrs. lIarie Caldwell
PART I, DEATH WAS "'USED av,
(snffT O. '.'.0. NO.. CITY 01 TOWN. S'.", lIP'
II,
IMM!DI." CAUSf
(ENTER ONl Y ONE CAUSE PER LINE FOil (a). (b). AND (e)]
(a) Occlusive Coronary Artery' Disease
DUll! TO, 01 A$ ... CON$,QUfHCf OF:
Years
CO"'OI1'IONS. If ANY.!
WMICH OAV! .ISf TO
IMMIDIArt c.use (0),
STATlNO TH! UNO""-
LYING C:AUSE LAsr
(b)
OUf TO, O' "'5 J. CONSEQUENCE Of:
(e)
P.A.RT II. OTHER SIGNIFICANT CONDITIONS: CONOITIONS CONflllUflNG TO OfATH I"'T NOT 1.,fLATED fO C....USE GIVfN IN ,...U t la)
~t.;'~gt "8il~~rgeT~).fi~io OR
~ilyl
INJURY AT WOIII(
('HeIN YIS 01 ....0 I
t MONTH, D.Y, n....1 HOUR
if YES Will 'INDINGS CON.
SlDllfD IN DI""'UN'MO CAtIII.
O'DU.'...
'""
HOW INJURY OCCURRED II!NTU N...rUItt o. INJUIY IN ,...., I 01 'A" II, IffM I,)
20<,
lOCA TlON
M, 10d
IIRflT 01 l.f.D. NO.. CITY O' TOWN, ST...",
lOa,
1Og,
CEIlTIFICMION- MON'" DAY ,...
'HYSICIAN: TO
'ArnHOEO'H, I
711. OICI...UO 'ltOM 121b. ,2k
CERTlFI"'TlON MEDICAL EX...MINER OR CORONER, ON 'H' ..... 0' 'H' "OUI 0' 0"'"
UAMINAnON Of '"I IOOY ...No/o. TMI INVUJlG.TlOH, IN MY O'INION,
~~:.TH OCCuttlO ON f104l! OATE ...NO OUI TO TH' C...UUfS. sr...TfO. Approx 3: 45 P.
CERTIFIER-NAME IT'''' 01 ..'N"
23. Roy L. Clemons, M.D.
MA,llltI~"+OQtE.SS-CE~TIFIER R d W
2ld ~t)u U.Lmer1:on oa est
.oN,"
OAY
n....
....t LA$T s...W t'fIM/HfI "'LIV' ON
MON TH 0... Y YlA'
I 0101010 NOT VIEW THE DEATH OCCUHED ...T '"' -'lAC'. ON fHI
lOOT ...ml DEA,". f HOUI I DAn. AND. TO '"' IISf
0' MY lCHOWLfDGI. D'If:
7111. 21.. Mo. TO ,"I CAUSlCSt Sl"'TfD~
llb ,-
21~" Largo Cemetery Largo
FUNERAL HOME NAME AN"" AOORfSS_ (SU~T O. 1.'.0. ,..~.. CITY O. TQ.~N, STAr,. lIP I
5. MOSlil FuneraL HOMe - 8u2 Nortn Ft. tiarr1Son,
IGN4TUI,'E r::-
YU.
HOUI
CEMETERY OR CREMATORY-NAME
33540 1lO
Cln 01 TOWN
$T..."
Florida
, JJSa5
Clearwater, Flori a
A CERTIFIED COpy MUST CARRY THE EMBOSSED SEAL OF THE REGISTRAR OF VITAL STATISTICS
I hereby certify that this is ~ true and correct copy of a certificate
on. file in the office of the Lucal Registrar of Vital Statistics of the
Pinellas €ounty Health Department, St. Petersburg, Florida"
~{;{s;:.~~, Deputy Local Regi'trar
.JUl 1 7 1974