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2 S AL RESI ~E i~iresas:,t ~u~l 'I •.ra t._t~.,, na-!rc:r I.Gvr rla _.r.,n 1
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1. PLA E ATH 'i a STATE n CU~ry
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r IS PLACE OF DEATH IES= I~ c CITT, TONN, OR LOCATION
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h CITT, TOWN, OR LOCATION INSIDE CITT OR , a _
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J HOSPITAL OR S IT STAI 16
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7. NAME OF
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MARRIEU
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I1. BIRTIIPI ACE
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CUUNTRT'
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10. USUAL OCCUPATION rGi r E~ ~-id ..•l
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1!. FA , MAIDEN NA\t F. $ti~a ~,~~A
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ISM W'AS DECEASED EY IN URS~ED FORCES.' If. SOLI-L SFCU RJTT NO. 117. INFORMANT
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1.~a, r. ,, .v ~.:nl a.,a a,I ll(>n. [err .u ,:r dLLr+ nl wn~.ur1 INTERVAL BETWEEN
1 USE F DEATH iF:~trr ,,:~:y ,.cr u~.:+. [~'r I,~z f.. ~.,al. ! ~ a ii : ONSET AND DEATH
PART 1. DEATH WAS CAUSED BT: i O~~S
IMMEDIATE CAUSE ~~ Qp~DaT~
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•ad~ti~aa. ~,f sae, I DUE TO ~t) __ I .-.. -_._ - - - -
1. .~irn c,er r~< i,~ I
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- rt>t rf the ~P1rrI~- I DUE TO cl - - -- --
OT RELATED TO THE TERSIINAL DISt:ASE COV DITION
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1!. WAS A
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OTHER SIGNIFICANT CONDITIONS CONTRIBUTING 70 DEATH BUT N
.~ PART 11 PERFORME~
NO
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GIYEN IN PART 1 .at TES l?
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DESCRIBE HOW INIURT OCCURRED. Ik'atrr eiturr d rn;~u~ ~ 1' ~t t or k'ut II cf rtrm Id I
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206
HUSfICIDE
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~,,, 20.. ACCIDENT SUICIDE
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20< TIME OF Ilo-_r. SS~.mlh. U.a.~ Sr.r
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INn1RT > m.
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OR LO ATION
TOWN
201 Clt T STATE
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EOd. INJURY OCCURRED ~ 20< PLACE OF INJURY fr. f m or >tr~•a h°mr, i
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'`' WORK C] AT WORK Ci ~ ___ --'
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21 l aU<nded lhr de<rmr.l from --- - _ - -
Ur>tF. cvn.:rr~! at ~ r.n thr dstr .ta[rd otuer. tr+l to the t.at d m> Ir.~.~a:r.f[r, fr.•r lh< n~:as d>t<A.
_ 122l. ADDRESS 122c. DATE SIGN D
22.. SIGNATURE ) «orUUe) a
t>le:
23.. BURIAL, ~ 1R/n, ~ 23<. NAME OF CEMETERY OR EMAT RT 123d. LOCATION it'~b-, too w nw:atyl (,
REMOVRL ~S,<cdll Y ~~ ~ Part ~ ~troolcfiela~ ~OOA~ia
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2(. NAN A HOME AND~R ~~ i. *A~h ~. fJt~~ia ~ ~~~~~
A ~ 25. FUNERAL DwI1lEC'FOI~
DATE - 'w~a-,.i,.py'[' •
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that I have carefully
I hereby certi~Y r.cmnared
the within certificate and r*lted
examined tnal certificate a`' prie.L-.to bo
it with the orig- ermit and Yin"
i~r issuing_of burial P
copy Of the eam~
ect ~'/
a .true 2Ylij-:dAZ'r' this-~--_"daY of
~':i; `:~f$rC~~?atr-,~auwatoea 19 ~-~
J
-a.3~ -";~•'~~ ~• lth Cc~isgioner
FLIED AND ~ eca ~ ROOK
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1962 DEC 17 P!1 I : 24
ROGER POIiRASr CLERK
ST. IUCIE COU~11Yr ELORIOA
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