HomeMy WebLinkAbout2075 rni. b~- /TAT[ sOARD oR ~tt~?~nt ~ERTIFICATE OF DEATH
co~~a a eUR[AU OF VlTAL fTAT1iT1C~ fYAT! 1ryL~ NO. ,~2
1•a.l FLORIDA
ord rh~n DIRTH NO. RCCIbTRAR•s NO.
p~op•rl~ 2. UsUAI R[flo[NC[ w?.n.4,w..1h..I /f:.d:rw~..: R.~i.+wW~..~.u.7..)
~ietuted ~Utt O! DtATM COD6 NO. (
•nd rlll a. COUMTY STATE D. COUNTY
Da y1~eeA - CJ'ti. ~LlCll.°
!n p~~- D. C~7Y, 70WM.OR LOUTiOh IS iLAC[ OF DEATM C. CITY, TOWN,OR LOCATION t. IS RESIDFMCE
•anaht ~MS~DE CITY LIMIT51 Ik51Df C~Ttl LIMIT51
rli,. Fort Pierce YFs~7 „o? Fort Pierce rES~] ho?
Q, MAME Oi (1/ not n11apR~f, /iN IhtK addrsw) IEMGtN OF I. STREET ADDpE55
K 011 A FAhM/
HOS?ITAL OR c• n~~h Ct ? ~~AY ~N .6 12~'] S+. 2 Jth 5t • YES ? !q~
IN57iTU71pM V J 1C. J ~
3. NAM[ OF El'rX Viddie Lat OATE MonlA D~~ Ysa~
(o7~1W o Prtbf) ~''.19.1'1 t~BC~ 8tit', CEATH J~une ui ~ 6
S. SE% 6 COIOR GR RACE MAIIRIED 1„p MEVER MARAIED? 0. DI1TE Oi l7RTN 9. AGE (!e /tsri Is Vh~ER 1 l'EAR ~ppE~=~ HtS,
3 I tAQ~i) h/..u. o~w Nw. X:..
~ i t• N.31e '~lhlte wioowe~? DIVOR[ED Allg. g~ lg2 ~j~
~~a~n~r IOC. USU+1L OCCUPA710M (C1ae kirldOJlvOtk doAt 10G. KINDOF BUSf~lE550R INDUSTRY 11. BIRTMPLACE (SOIt 0~ f0/tl/A CV4tU//) I. C1Tt2E110F wNAT COUMR~1
~it~ p~t- Q.'npmwt J o(tiqOti nrn(Jretirrd)
¦~nant Tes~~oar~ '~ispa~cher Telephone F'lorida USA
Dl~Ck 17fk ~3. FATHEA~S NAME II. MOTHFR'S M111pEN NAME
trpa~riter Edgar B. Padgett :~Tella Lee
IS. 1Y~5 DECEASED EVER IM U. S. ARME6 iORCES~ IS. SOC10.L SECURITY NO. 17. IM?ORMAIfT •~IOMATYR SS? ZI~DZILla S. S~elr
1 Ya. +o. rwkw..I lll r~a w s Mb~ ~J «~+:a1 d
Yes II 2b5-2~--6723 A/hen . ierce, a.
TunK~l ~S cAV6[ O~ 'bGTN (Enltr 0+11/ ons caw~ pnlint Jnr (a), (D). an~ (c).] IxTERYAL lETWEEMI
E1~~ttOT ~ART 1. DEATM WAS C~USED EY~ OMSET ANp DEIITH
•uec f~i~ IMVEDiATE UUSE t.> _-___3ronchogenia c ix mnnths
th• ¢at-
C 1 f 1 t~ t• Condfltnu, iJ an/, DUE TO {6) _
•ith th• rAkA pwe rire eo ~ ~ .
1 o e ~ 1 oDu?e tutte (el. , ~
reai.er.r uati~/ Me rnarr- puH ro (d '
l~in/ aanu (aat. ~
• 1 t h 1 n 7~ ~ pXRT Il OTMER SrGNtilUh'T Cp~617pM5 COMRIlVfIr+G TO DUTN OUT MOT REJITEO TO TNE TERMtlW. DiSEASE COMpTqM GMM !N !MT I({) - W 5 A OPSY ~
' hour• at- r ^ ?ERFORME61
t~r d~Rth ~ , YfS? MO?
o~ De fore ~ n7p. DESCt9iEE HOW ih1URY OttURREO. (E~(n ftatt~~~ of I~jur/ fn Pafl 10~ PIAI yU~ • ~ ~ ' ~
f~klna sn~ ~ ACtIDEMT SUIC~DE MOAtIGIDE . .
'teyo~i- W ~ ~ :^-f "
~n oC ~ v
J 20[. TIME OF Norr MonU, Da~, Yra ~ ~ ~
-`'dr• V ~MJVRY a.rR. ' .
o P. . -
W
' ~ 2l?d. ~N1URY OCCURREO ZDr. ?LACE O~ ipJURr (s. p„ 1+i or ¢Mu! Ao+ne. 2D/. CITY, TOWN, OR LOUTqN ODUMTY , " .~STATE
WMiIE AT ~ !qT WHI~E ~ ~°1TM• ~~O~y, N~[[!, OjJ[tt dl4., ttl.) .
WORK AT WORK
21. I~t~~nd~d th~ d~cvassd lrom ;:OV . Zg ~ . to June 2.t~, .19 3 •nd /ut uw n,~ ~li.~ on JllIle 21 .~.9b j.,
D~~tA accurr~d at 1:~~ m on th~ daN ~t~Nd ~Do~~; ~nd to tM b~~f o/ m) knorl~d(~. from th~ uu~sa WNd.
~11 S t~~s jj~ s14MATYR[ (Dtprtt ar (U([) IZD. ADDRZ55 2It, D~TE SIGnED
ar• to 0•
~a.yi.e. a t~~elvin 'rolko~rsky, ::.D. 808 Orange Ave., Ft. Pierce 6 25 63
•~!Y?at~. ~~R~u, qtEM~~ION. Z~ pA7E j3~. NAME O~ CEMETERV OR C71EM~TORY 23d. LOGATION (GYl/, fWOf1. Or tOYn~/) (SYadt)
REMWAI (•SDlClh)
6 2 6 Hillcrest h`~-a. Gd~s. Ft. Pierce orida
V• 8• ~ D 19 j~. F~MEAA~ DIRECTOR S S~GNATURE ADDRE55 25. DRTE RECR /Y IOZAI REG. Z6. REG~STRAR'S SIGKATURE
Asr.1958 '.11to:~ ';i. Baird 1~. 7th S~, Vir ' nia iJ. Barlar.d s, r.
- FI ~ ; , ~='~`CG~R~~D
I herelsy certify this to be a true and correct copy of 7he Loca. '~{Cj$~ _ 0 K
Regisfrars recc,rd en fik in the St. Lucie County W.e:~ith Depart-
~ meM at Fort Picrce, Flortda.
(Waming: Nox vb!id unlees raised se~l the St. Lucia "r`;~ 5 i ; f; ~
County~ Health Department ~s ~ffixed.)
, N. D. ARill'cR, 11~. D. . , . . ~ ~ :
. . County Health c7ff+cer ~ lxal Registrar ~ ~ ~ . - ~ ~ ~ ~ ~ T Y,
_ t= LORICi;~
j ' - - ~ ~ l~~.A.~c~ - ~ v , ~ ) t~,_..~.5.~?v.....
pate Cleputy Locai f?egistrar ~
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