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OFFICE of VITAL STATISTICS
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:I FULL NAME OF CHILD_r~!LJt~ :LCJ..r.Jal,- U Child I. not yet named. man .<~~tt~:'
.- ---- ~ eupplemental report,. .. directed. ~~~
3'sei"ot"AA /.. (a> Twin. triplet.. (b) Num. ber n oi. er 16 Le t- 6 Date of $. ~~.
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CERTIFIED COpy
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18 OCCUPATION
(Nature of Indiiii'ii'f'
I (a) Born Alive (b) Born All
1 and now living but now dead__~
· CERTIFICATE OF ATTENDING PHYSICIAN- , .......... ~
T herebh certify that I attended the birth of till. child, who W&lL.------a.LL.v.~--____&t~~-9.......
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BY:
OLIVER H. BOORDE
State Registrar
ANY REPRODUCTION OF THIS DOC:1MENT IS PROHIBITED BY LAW. DO NOT ACCEPT
UNLESS ON SECURITY PAPER WIT'" COLORED BACKGROUND AND GOLD EMBOSSED GREAT SEAL
OF THE STATE OF FLORIDA AL TEilATlON OR ERASURE VOIDS THIS CERTIFICATION.
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DEPARTIdENT OF HEALnf ."I.NO
RaiN3IUTAnYE SER\'
THIS IS A CERTIFIED TRUE AND CORRECT COPY OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE
WARNING: