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Guthrie, Amy T
,. Ii>>.......... , 1\ ....}i '.\>9F.~ICE~f.YIIAL STATISTICS .ii ......\ .............~ )> .:'...I) . ..).i.i\~~~u '. . ......ii .........iii .... ........1.\_ ~ ..L iiii '>i " ......... '_____i...?} '.' .........., ii ,( ii>i CERTIFICATE OF DEATHii)> ...:.......>.__ " LOCAL FILE NO,... FlORIDA .......ii ...f'cl. DECE~I;.~Tf~AMEii FIRST MlOOLE LAST 2. SE~.... .illl )Ii }i.AMy,> T. ....... ...... GUTHRlE\iiFema .~.'" ." J~ D,,"[l.;EO ~~".~DJEA~TH' (Mant,,"..~Oay..~ ~~air,)" .... 4. SOCIAL SECURITY NUMBER >. SaAGE.Lasl altlhday --:or Sb. UNDER l"YEAR .... 5C,UNOERIO.V .: ."i 'i ". .... ....... . .....: _ ......\ ..... .Jye~). .........Monlll. .Days ii~~rs l~~~~le .\ _ "'.... "'>'?"''},-l'IF._ ....> qr:; .... .i'" "'.' .........1'..... ....... ). 6. q~1'E' rOWF BIRTH (M/mIII.DflYi~ar).. i........IJBIRTHPLACE (City and State or Fot&ign Country).................> ...... ii.. .. e. WAS DECEDENT EVER Ii\lU s. >0-:..... _ ............ .' ..... V....i..-.:._ ...>..... . . . ......... '.ARMED fORCES? (~so/.f:ia)'. DECEMBER.14)i1898 .......... DELAWARE COUNTYiJOHlO) . .hi -YE'No . .i' .' 9a. PLACE OF DEATH (Clleck onlyona: seemstructions on otller Side) .... ............ 9b INSIDE CITYl::IMtTS? (rils or i - ~i:j;e:O::~~~4~:=~i~~~;:~~~:::t;r~;?\m~().~R:iN~~~ Home R='~::~~~.h~~~~BON OF O~Ai~(..~~. COUN~~;~~TH ..' ...... ,.' '...... <....( ..... ....'I1'M"'1:'D . . ". .....LAKE.r,jNTl........ .............. >i< U\ p6tk~~l ...... ~". )<la. Dr.~~T'sSh;)j~~iOCC'J~ruPATlON .... lOb KIND OF BUSINESS/tNQUSTRY II MARITJ.... STATUS -Ma"0--- \2~ SIURVIVINU SPOUSE (Ii'",!", gtvema'den nii'rire) , e!r...1....." .,\(~?<. . . 'U:.ii I ~=~~a:.s:c.~fowed:' ....:}....7;-.. , ......... iF . ." TEACH~R ::':" '. .'. ........ . .... . EDUCATION < .. I' WidowecI...i w"', ........,...................(H ." '. , ..' ':'-13a, RESIDENCE STATE 13b. COUNTY 13c. CITY. lOWN. OR LOCATION 13d. STREET AND NUMBER .......... ..........'...... . ,,' .~ '.......-i.. .;....::..."... ." ...:....:...,... ....( .....................} ..... ..... .' ".:':: , 'i?iH,,:; ii. .' .'.........}... ..... ........ i>~ ,\n...,<'iijL] ,Ld~c.}t\')...,:", i" 6.(L~A6~~kRBRlVEi~C ~"(~;'i' '\~H!'1.SI.De CI1>r . (13f:j:IP C9pe' . 1~~AS DECEDi:NT OF HISPANIC ORH~A~11'I~,AN;.ORIClIN.-1 ..: 15. RAQl", 'Ameflean' !;"'~IJa';"n" ". l~cDECe;PENT'S.,EOUCA1'ION\.'",,' ~ ..: ./..:q~frEl? ~~fNOI;..i <> (S~ Ncor Yes - If yes; SP8Clfy Halllan, Cuban. ( ..... BlaC~IWhtte, ete .' . '.JS~c'ly p'!'y h~!",st gra~~co/!!Pl . """i ...... '}it:. . 'i> i ..dt!~\J.~~~~~'ea~, 'ttc.J -- ~ '-)~ ii< SA':'!- ".~~~~l CoI"t1 . 1#<5 I','" ..... .... ,'./YF.S) <.... ~f'.i> ..............<.>> >,' lT~\!1.12)i>li(5+, · : :. "'17. FATHl!R'$~AME (FVili.:.M,dd/e; Last)..) ................................ .l~;t,!OTtiER'$.NA~yfit$VMidd/e, Malden Su:~!0~E;' q.,.. ..: ...... . .' .' , ". '. ORVILLE TAYLOR EVA STRONG .' ....................... .. ..' ..< . 19a IN~9~IlAAN:T.S NA~~(tr~P,int)>i} L$b:MAlLING AODRESS (Slree, and ~~7~JL~r RUf81 ROUlij'N~r. CirR(~~: Sla",'?iPC~~I. ..... , .'.ii1i1>WILLIAMiHl> H~t~UMi ...... .ii! ..>213 ARLlNGTONAVE1.NAPERvrt;LE;( fLLINCHis>. .'. .Ji ~.ya ME~ji~ OF?'SPOSITION;(G2_ .:il~;t '.' ." .. 20b ~:t~~~)~lSPOSITlON (Nama 1!0m~ :f,~~wy.,.;\)7 . }~~OCATlONi- Cl~ Oftn~~WI> .... -ii _Bulllll. ~CrratlOn _~ITR!:~~~!fr'~lfe ". ;':;".. . .SiLi iii} '. '.rtit ;.H i ~l!' ....... ()~r(specd)I)>} .'iUKEVlEW CREMATORY, ......i}; WiNTERHAVE~/F ~ A'fa SIGNATU ~PFFUNERAL SERV~CE Cl!JIlSEE OR... <i 21~i~ICENSE NUMBER 21~'N~eE' .AND ADDRESS OF~ACILlTY ."'" _ f'ERSO .ACT~NG SUCN ~f J (Of LiCensee) Thornlon-Holco~Memonal H&ffi(i . . .'. q .....}. ?9i~ .' T< . . ..... ......... .\ 18~.lSoUlh Flonda Av~W,,~ . ............. '.' ................. ...~.. .~.' .... "n/,./{J y..} /><.2033..< '. LIIkefand;.Aorida 33803<>:< .......... , ..' .' ."." D~ '.' ~ l~be&tol my~n~d ealhJ!(We~he lJll'Ifl. d ~ a.~.rill cilil~d~'!1I? l"1> .. d:i 23a. On lll~bili.s oi'$tam'nall~~.:and/or(r,.esllgal'o"iih myoP'rnOildHt~o;mwr .~:.::l~~c;~:(:~:~:~i~ H. '.' r--...;, ~rf;'" /f ~ J} .....n Is,1::u';;:~~i:W;'acea~d~em~~e~~~$ej01a~~a;m!r.ass'~I~',;{,:, .llk2a~.'<OAr~$IG;.N~ED: (M;~~O',o.iiY. . Yt)' I> :MfC.HOU~OF Dee\"T'iH.> . '., 4 ..~. ": ..~ .. > ..' a~23b,<<[A-r,.;;;~IGNE~D~; (;"""J7' . Day. Yr.)..... )..\../.1'72;3(;: HO.,SV..Rt O_il.'DEAJ;1:!. ..... """':'" . .liCl'i:!(~.2~ ....... H7a~ / . rSf) .... . .~.../ ,g~ '.i). .' .' . ...i . . .'. ";;<.. .,' cr~ ,A"~~ ""'~'r ~ I........... . .. ..ehi 101, va . '.. ..... ................... . li~ 22.11. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (TypeorPrmt) 110 23d. MEDICAL EXAMINER'S CASE If' ................... '. ~~' ~w :' ~ .,.........../ ............ ...... ::l: " ." \ ...24. NA~7JANDAOPRE~OfCERT"*~(rH~SI?~N,MEDICALEXAMlNER}rl\lPl>orPflnt) i. ;.../'ji'..c p.t:.., d{\ .S/ :j\; .... .' 'G"it1re:t{ Ie:}A/l?1(iS'M.~. . <<92.raIilS-M li:I.:f!.. 7i? ~~.~Al~ .;;r~fl:0..:J~ .....;2SLsueA,.~~01 -~~~URi:-~{' "l;": )~~~4!"; LJP~ REG~TRA2 ~SU~:-"'.i), .'. .Hy-> ........ i1:!~:;; ...,~::r~=::..-=- "'~"'::::::'c~:.':''"W'' m~' .~:~':~t"-~"!'I".....,{~ 't""":i:==.. '..... .' . ..... .... ... ......... ...........>.......... ,:. . . . ....r "Qeath' ".. . ...../. . IM,MEOI",TE CAUSE (~(nal' .................'..... ....... . .~. .. . ~ . ....... . ... I . ..... .......... ..... : '.di$.~~t:cond'I~~N~)... 'r' ..... ...... 6'S'~. -'-- '. 'cL~..\'.. ..~~..)~...\::~c....;;...... .>"1../..., ~0':I~!\~~~rhI. ..... ,"\a../> .' '77~rr~\) -~.~ .( /? .~. .i'i:'\.!K);2~iIl.,'" ...... ii ..... A)i?UET9 (O'k~ A~~EOUENCEOF)id/.ii/ .r> .,~ {H>i . if'< .: .. ~.t~~~r::!~ilml~~*~~~::; . ." ~jir i/, r.,r.,? ~....;~.~~~~H(,$'I'~ 'H>.{" _ :..L 9tnd:~~:~~~ .:~i .. ..... . ". ~:.:I;~jACON~~~:~NC~O~~. . ii ................ 'ir .<C. '. .....:.i?,t .... ii:'(, h': ;..': _ I..... . .,...~,. . .h . '. . ....... DUE 10 (OR p..s A CONSEOUENCE OF). ....... . .' ........ ..................... I ........:.-;h.... ,.........).......... d." ................\H<........> . /'i . Ii. ......... .....F...I.A....R..T...I....k.Other s'9n"ieanleol)Q~lon&(;Ont!'~I'.'WIO clealhbut nol re.u_,II:."':9~ In l~e- . ......... 27a wAS AN AUlOPSY..~7b..WeRE-AtJTOPSYFINPING~j .(i' h~~.' OA$E REPO . .... ~erlr!l~eej~~~s0e.~,'JW'fl,'n.Pli.~;I>... I'" (if .'. .......\ i~~1FOr:oM~JF:gD?' ,., < '. USEOTOC~~O~Mf'lf~TECA_U~5E~ .y.'. .i.lc<~~Zf~~} '4 ..... ......... ...... ...... ".} . .. '.. '. '.,) . ....,. ........ h,OfPEATH? (Yes or 0t . '.' '..n~s Q(t'O) . h ,:.....<<:r. . . . . h...... . '. .\ . '.'i.'" . NO. ....\/ .... . .. .r.... .... i.>. H' YE . .f?..... 29. ~:E~1:Cv~~k~S~TT~~~~r..M '~alfWR~f~v 1~~ENTl9~EDlfi>AATI(ir'I~:TltR CONDITIQ0.F~'H"'HI5j'rWAS ~p~~(l~~F.~>~~' ~If O~~U~Hlr~9:iOay. lit .,' 3MONTHS.t.....VES.. NOJ" ................... ..............,.... . '" .......... .......'........ <\.,.............................. .............. '" 7...-;:................ . '. .. .., ...,.........'... ..... ...1 31. PROBABLE MANNER OF 32a DATE OF INJURY 32b. TIME OF 32e. INJURY AT WORK? ~_2d DESCRIBE HOW INJURY OCCURRED ....... ..,l,)fATH (Spe!'iIr):. . (Mar,/h. Olry. -Year). h-;JUAY\'r~sor NO'i. -----:--~-- '-" . ",.> .....~t~~~1~7~1'............ ..i. --;Y\C iM Y..Ci iii' ..............C. .\iii.................... h .I.......... ...... ......... ". '. ..' 32e. PLACe OF INJURY AI home _;"ar~.: C .32f..LO__CA~\lilO_/II(~ and Nu",ber %Rura/R';rCHi/arNumber:.tC)'ity.,:~ or.;T~own. Sl'Flate.).. . '. ........ .. . , .' .,'.... . ....,. .. . stre:~ek,.tacIOry. ele. (SpecIfy) ..>....: i ..' i .... I......::..;..,}.....,. .... . .. ... ....i.. .......... ...... .... '...... 01.;' "b"c. LL' < . . .. i.i .i .. ,i . .'.i<. .i;; i . '. ii. ;:i: . ......' <i ....... .............. ..... ." ........ i... ..' ". -'T --.; ~.i" ..:.:....... ........... >/i,._ _' .......... ...................... .X~ii .~. ;/~ ;,ilU G~ l~RTIFIED TRUE AND CORRECT COpy OF ,HE OFF"';~;:~:5:r:~~"'"~mrIC~ igg~7? ;;- ". .../ i/ 8'1"./1.... .. .... /2/J' . - . ........ ...iiHi ii> I <.~.....~ r~ State Reglstrar>i / > iii/ hl~'t"."~.. . ............. ...>.... ........>> "~~ ""~ ............ ...../.... ................ ,VorL, ~ W ABNING. ANY REPRODUCTION OF THIS DOCUMENT IS PROHIBITED BY LAW. DO NOT ACCEPT i"" . l<!'..;3}-:'".....-: "UNLESS ON SECURITY PAPER WITH LINES AND SECURITY WATERMARK ON BAC~ . I<i i.>ii AND COLORED BACKGROUND AND GOLD EMBOSSED GREAT SEAL OF THE STATE OF ~ ".....i 5 FLORIDA ON FRONT. ALTERATION OR ERASURE VOIDS THIS CERTIFICATION. .....-.!! '... It S 40 S 4 d_ .. ._ _ HAS FORM 1564A (6'93)\~ ~, J .. , I':.:~ 11:; ,..... '.' ~. " ........ '.. ;ii . ',' -. ..': j ~ ..i.. .....: ....... . ....,.; ~ \ "t 'I~ '. .~~ " .~p '''.' 60 " ............. .. FLO i .,... . . . . " . " ",'",: '"