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~ERTI~'1CATE OF" D~A'Tt~! ~ ~t T L O!~ I D A •-r~,i uo.______ , ~~Y~vr~u.:_r,~~_ . _ - R[Q1~"1'NA~ NQ. I ~ ~ _ - ~a.:a~r~+.r.~ae~rn.~r.~ m-_ o_-.mr~.~.E- -=a.- -..sa-~r~~-~ _ I. Pt.AC~ OP D[Al'N : Cwi wo ! 1 U~UAL R[SIO[NG[ ~~s~... ~~~.w n..a u srrsr. r.ra..,. ~.r.. .s . COU?~fr a. L1Aff i. COUNTT .+so~~. - -~~~,__~14----- - ! -~ifi~?2 _~___~.~1~`i43i . St. Lucie CRY ~u .ww. .aw.n. ~ui~u. aL~L?[.i c. lf?tSTfl W a Ctri ~tr .aaa. ..v~~c. ur;~ xuut, 4 Ow ( i4'TA1' ~Y Y4 s~w~ ~ O~ y~ D ~vy TOWN _FO~'t_,P~Ar~-----~_ :.M~~I~~1___ _.iOW?!__ .4'OI'_~_ l~a~~t~ . ~ ~ !VLL kAYE OF ~[i r~ as ~u+1 ~ '~.c~cw~~. ~uws ~tr.u K !.~uu~i~ d STREEI tt rrn: ~~n ~...aa MASM t AL A C ~ lFZ3 ~y,, IMSIITUTI ~ ~ ~yii~i~--,aiJa~~~,-__• ~ t. NAAIE OF ~rw~tt a. c1Udd1~~~IDr~-A.~a t:.siJ l DATE ~ DECEA9lrD OF I~•~•ta1 16wr ~tYav~ /7 w)'ri~t 1 1 1 1 A!1 6E~TTi ~ + ~ - - ---1, - ~ - ~I ~Y s ~ a I~;..r? ~ _ ~~9~-___l.~t-.~-1. Q~ j: i. SY7( ~ k CC~LOi 00. RAGE 7. Id~l~IiD, NEYEI MA~~16p, ~ i. DATE O~ ~IRTM 1. A6; , i~ ~ry N»yr ~ ~~ws a r~t~ ea ~ I ~ W{QOM'[D. DiYORCGD .~p-en: ~ r~ ~t,wl.s~ ~Y~~ ~ ?~a 1~~ rt~. MQle __~hi~s_._ , _~S~rriad-- 2-4-1~II~ - ~ ~ M~. YIUA; OGCUtAT10N,Ut.. R~od f w~:.~C6 KIMD Of 1:1214/SS O! IN~ ~I. ~fRiMR.~CE i~r~ ~ f~~r• i1 C~TlX~1 Of WhAT ao.. a+n1.K rr. d+wtW 7t~w w.a 11 ra7n~~ ~ DVSTx~ . 0f0:p'Pf~TRY) 'I- ~ ~ _ .__L~+?A ~ .-.~~,D .Ll~."l~Q? • U FA 'S K/Wi - N. MQ t hiA~DlM NAYtE iiQQX'Q~!_~~.9.~.nQ.~IIIl ~~l~i~ _U~~ ------r.,_", L'flnnl a Tnr~lra~. WAS DlCfAS80~tRfM U. S.A~l1i0 fORClSt Sl}ClA~ SiCUtir1' ; ~7. lMfOtM~NT'S StCHAi'tl~~ n~~a~ y~~~Qan ~.a r. ~r u.a..r.l i~tt ~r. r~ti ++r ~ YY~ d wrrlw~ ` MC~ . w 4i ~ a. _Jl ~ S ~ x[] AOORfSS ~1. C~USE OF DE1~TN i ME0ICAL C[RTIFICATION ~'tMTOtv'hl smw:w .&atar aab s~ us.' I CISEASE OR CQND:T{ON a++~cr ~MO oswrM ~ ~ per 4n• tur ~s). (i). DII~Cfl1' LiAO;YG t0 D~ATH•~~)____.Art.~ ~nl wrnt~ Hrasrt ~ggag~---. ' - t. ~ _ ! f?ypertrc~phy wi th Hy~srtenei.on i ~ •r~., ~w , s, o+..~~au~ ro ttil _~Cllt.i-~L.Y'A21S~ _~l~C~l~- SriS~Bri~ 'l, wod~ o! :.~nwy..Y~ri~l oewiwow~. i! a.~ ~ w~A aI An~rt /aUrn.~rw to f.~t s8or etae~ t~l Mut- - - - catA+s~g ste. li ~~swalsp fA~ w~d~rlAw~ owrs~ +ri tAf iA.w~, i~,•rr'. D+J~ TO tr I _ - - - - - cov p6oe^w. r 4 ~~~f fl Ci1HiR fIGNIfICAMT CO~IDiTtOkf b awrs~l irstA ~~'~wd~'awu wrwer:bstn~~ te W Ir+ti ~t rnt ~ • ,~~aJ te Nu ~as.sa~ v. aewJ~Kow ~cr.~w 4 drs tJs. _ - - - - - _ - -w - ~ 110. DATPe Of C nOM+~'o ?e,VGt FIMCIN:S OF OPf~lATiOk i 1~0 AUTO?5t1 - - +e~ : i+tr ~ ~ - - - - - - - - - - - - - - - - - , - ~ ~ ~.Pri?~At~'. !v«~1~ ;1 21h. ~LACF OF INJU[Y ~a t.'u .ar e*.~:t 7~< (Cf~ O~ TOWN ~CGUkf~ -~3lFTEi ~~1~ ACCICsIWT '~.rr. 'a.'n. tvtrar~ rttan. tA~~ !k`t rc : !f ratal ttaii Yl'RA:. •U~CIL`f MaY.11`i.LL7L" ' ' 'Y'_.~_._.._..._ ' _ . ~1 21d. T~ME ~~.n~r i~. T..., S~r. II• ~NJUtY OCGUIRED 2!l. NbV? jSI~S IkJURY C1`,Z:vR' . ' ~ ~ '~f ' •~~it i.!'~ ro. s~~i~ ; IhiJU~'! ~ ~~.r l.J e~ ro~t ~ - - -.'--r ~ ~ r2. 1 i~rriLy eerliJ~, liw• ! attewdeu th.r ~iecea+rd fr~.r+~_~ , t~~~il,~j' Ztj~ tlWl l i~Mt ~p~r M;t ~letc•:~. t ~ t ! ~'h. ~ -a~i {>>~r(_ h~~! de4tjt ~r-~~tr*dd a'~-, - tn . ,"um !hL /17'iff• u~~f m? ~dlt f Ot~i. ~ ~ ~ 2ia SlaNATUR[ Cs.s,.s or du) :lb ADD~SS ~ L1~1~~StCHEO ~I. H._GoOdwlAi JX'o, ~,L~.t ~'.~i¦ l.'L4'~`4Q. F1a" -.'••;'~,.~'~`.'w,,,`~~Ci..~;a l~a. f U II I A~, ClEu~. ~ D.~'~ i4 ?MME OF GEUEIERI' OR CRFV~IORY 74d. LO':ATfON 1CWt~, bry,'M'Mieq} i4Ui ~ r'O ~QMOvAI .,.~,ry• ' ~`emov~,~'` . ~..15~~~ . _ _._~iavaom• Fa~m3~~,~ C~tm~t~ Smith Hill,. - ~ D~if tEi; D!1' ~C~C~~ JtEi:+S~l~R'S S~6h~TURF 'S iUME~rt DIREC:'^~S:FY~r;;RE ~,f1 ~',`•.i~~ 15-I9~~__ An_Lt~~ -~.~~~~~...=:~tf.4~-=~~_ Uti,r•~~?. r.'-~n- ~ - ~ t hereby cer?ify this to be a true and cwr~ct c.opy of the local cn Regist~br's racord on fii{e in the St. lu_:t Coun!y F{taith Depart- ~ r mant 8f fort PiercP, F'~'+:1a. ~ amino;.Ncf_v31~d un!ess ra~se:! ;.esl of the St. Lucie r ~ ' ~ Gc~un~y He31•h Dea=~'rr,e;-,t is affixed.) tJ' t, ~ ~ '~D - , , N. D. Mfll'.~, M. p;_' ~ : c~l , , Coun!y ~~salth Off:cer ~ LQCaI Ragistrar r' ~ - i ~ ~ : ~ C-., ~ - , -if~ ~up ~ 1 s i r. . ~S ~ f ~ ' O O fTl ` 'L' t ?t O ~ pa~ (~eFwty locai Registrar „ c~ . r--~ ~oo~ 1~~ ~~1~