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HomeMy WebLinkAbout1233 ~ » ~ ~ a s,~~~ • ~ ihis be- BTATi BOARD OF HGITH CERTIFICA7E OF DE t" r i~ co¦es s iIURC'J.U OP VI7AL IOTAt11iY"ICf fiTATt FILE NO.- - r le~rl ~ac- t LORIDI~ ~ ord rhen BIR7H NO. RECIBTRAR'8 NO. pr„yerly 2. UfLAI RCi:.....'[ exetu[ad ~~C[ Of D[ATM CQDH KO. -(M~w~~r.rdi:wt l/wtli.d:a.: R.'ilww?./r.~dr.w~i~w) •nd • i l l ~~~'Nn eT T e. STATE D. COUNTY b e p 1 a e a d ~11.w_J. ~ T' T 7 T T Ti' ln per- D. UTY. TOWM.OR LOC~TipN IS VUCE Of DEATN t. CITY. TOWN,OR LOCATpN t IS RESii:EnCE aan[~n t ~kSIDE CITY LIMITSI IMSIDE CITY LIMITST f 11 a. N 7`t pl .7' YLS ? MO Q ~Y_ ~l~Y`t. pl rt`Ci! YES ? ff0 L. hAME OF ((Jwa{ iw Aapital, pire KreK a~d~r•~r) e. ~EqG7H Oe d. STREET AODNE55 lt09PiTAL OR STAY IN 1D ON A FAqMl ~~sT~TUTbti ~ ~ 5 _ S+. . 1 YES ? i+o 3. 11AMt Or Fi:~t .y[6dls Lar/ 1. DA'E MontA Day Yrar DLCCAf[9 OF (TYFK or prinf) ~OSe'~1'i 4 DEATN S. SEX 6 COLOR OR RACE 7, MARFIEO ~ M4VER MARRIED Q 8 DATE OF YIRTN 9. AGE (Iq yeaq 1F (JhDCR i TF,IR tF U~~D[R 2~ ItAS. 1a1! DvfAda/) N«.W D~r~ Hw. Yiw. t• ~•'.~le ~';nl±e W7DOWED? DIV6RCED J e 2 18 y1 alnl ~ ~Qp, U5UAL OCGUPATIOM (Clottindo/wort pcHt lp~. xIMDOFDU51NES50q INAuSYRY 1!. BIHTMPt,,1CE (Stotr pr jprtlpw lo4qlr~) I2. pTIiEN Oi Ww1T CWNTFY7 rith y~r- Qurfnpa~wto/vorkinpl~k.exwffrlirtd) ¦•n•^~ N.aintaince A~t 'r'ouse ~o d U,u,~ . L1eCf[ Snk FATHEA~S NANE 1{. M07ifCq'S MAIDEN MAME or t~p+r~'t~r Anthon 1{I7011 ~n a IS. WAS DECEASED EVER IN V. 5. AftMED FORCE51 16. SOCIAL SFCURITY MO. I~ ~y~pA f'tla ~~7 Y~ ~r.......,.,t..r.~ • ww...,.,.....s.r..H.......~ fVi' ~ U.'i171~1 i%.].ltoil r~. Ba1T"~' fl0 i.~Q j Q .{dsrai • 1 Q~ t. ~ - -D' r? r~ Puae r n 1 ~d. tANit A/ aiA7M (Enle~ mal/ u~t ta~au pra liru /nr (A), and {4.J INTERYAI BE7wEEM d I r• C t O r MRT I. DEATM WAS CAUSED OY~ ONSET AfiO OEATH IMMFDiATE CAUSE T.~2PZ1:1 4 ~'l7` }'pSl S ¦uot I11• th« e~r- ~ . ~ ciric+c• Cond'uton.,i/an~, p~E TO (6} UrC~'li3 ' • i;;~o;r~ • i t A t ~ e ~cAtc1 yapt ~u'~ lo ~ . - - 1 o e w 1 aDooe touat (o). ~ . alaNn lRt undtr. r~6latrar lyinO/ tauis dwl. OGE TO (d ~ ' . ~ h, ~ ~ ~ /AAT II. OTiQ SIGWi1CAM C(ylpiTpliS CG~fTRId11T1:YC TO UfATN OIJi ~pT ROJITED i0 iMC Tilllf~l/{AI, pISEA$( CpNp1TYfM ~~/(J~ N?TAIIT I({) . M'AS AU7dPSY t~r d~ath ~ : ~ ~ 1EAFQRMEDI o. n.ro.. Diabetes ?~:etast,atic vesp ,+oG~ l~ ' 2W. OESCRiif iiOW WURY OCCURRED Enrn nofun o Iw r~~ Pvl /~N Pwt itam'flJ. aaking •n~ ~ ACCIDENT Si11CIpE lqMKIDE ~ ~ / ~ r ~ a . ~lapo~f- u ? ? ? on at _ ,o~~. ~ 24[ TIME OF Hoar ~L(ont4, doi. Yaa~ - " INJURY o. n~. O D. W ~ 29d. INJURY GCCURREO Y.k, ~LAGE OT iHJUkY p., iw a atrout Aonu, ZOf. Cliy, TOWk. OR IOUTqM ~ CAUMTY STA7E WMiIE AT ~ MOT WHtIE ~ Jarm, /aclo7Y. ~treti, ojlfce blQp.. t:r.) WORK AT WOfiK ~ 21. I~tt~nded tho d~u~a~d 'ro~ Q'" ~"V3 , to ~~2~~~~+ •nd !ut ww him •lir~ on ~~.i-~L Death u~eeu~t~d+t m on t:i~ d~t~ st~frd ~bove; and fo thr b~~t o( my knor7~dp, Irom th~ c~u~as ~aatid. 11 2 1 6~~~ ~ f~Q~Ty*~ (p~pr~t Or fifkj 22J ADDRE55 b~ ~l~h ~ JCt ~ j2c, pATE 51GMED aie to D• 1 °~•?I •c• Nlva D. Grr D. ~ F~ _~t r'ierce Fla. 1-2b-Et~ aCCUtat~. ~ B~R~AL,CRErATIprr, Z30 DATf 2,3c kAMEOF~EME7FR'/ORCRENATORY 23~. LOCA710N (C1ly. lOtCa. Pl COUnlY) (Sall) RE~GVAI (S t~f 1 ~:i•;O~T~,~, 1-2b-E LUC;,~ CE:~.ET"~:i~Y CHICnGO ILLI'i~QIS • 5. r d 12 j{ FUhER~L DiREC70R 5 SIGNATURC-~_~~ q~pp~eral HGL7C ~ D~iE RECD. 0Y LOCAL REG. 26. RE4i5TRAR'S Si6t1~TURE W nsr.iJ59 ,~~o-~is L. }3o d 1-29-~4 hnna Lee Denzson d.r. - I hereby cev^t;fy this to be a r~ ue ~rd wrrect copy of the ~o; a Re~isfrar'a reeord .on file in the St. Lucie County Henith De~art- rrKnt at Fort ~Pie~ce;, Fbrida. F 1 L~ G A N G R~ C 0 R D~ D jV'?arning: P;ot va!;d un!ess ra~sed se :i ino St. lucie • K County F{ea(th Ue~.art~r,enr ;s 3ffixEd,) ~~i~~~ A'C~--w~.~ M. d. ~~niu~R, r,n. '65 DEC 10 54 , C.ounty Health Off~cer & Lacaf ftegistrar ; ~ ~ ' ~ ° j +'L ~"G~ ~ta.~~ ~T.L~~ ~ 15.~.,~tO,~,W : ; _.....J. L~RK Dato Deputy l.oc~I Re~ isrr~~ d, r. S'.! U C,' C U U P1 T Y, ~'LORtDA BORK ~~t)