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HomeMy WebLinkAbout1264 i re,~. e.- er~ra 1lOARD or Hrr~~.~ CERT1FiCATE OF DEATH q eoae~ s p7,JRCAU OF VI7AL bTATiR71~f fTAY[ FI~.R NO. lssal ree- ~'~ORID~ ord vhen BIRTH NO. RE6ISTRAR•3 NO. p~operl~ exscuted 1. ?LAC[ OF 6CAT'11 GOD[ NO. 2. VLVAL R[~IC[NC[(il~...Is..tt:.w1. f7:~+.~~N+: Rr:/wr1Ur..tiwwww) •nd ¦ill Q' ~Uhrr a. STATE b. COVN^/ ~ be ylaeed ~ !d S n prr- D. cirr. TovrH, oa WC~Tror+ t, ~5 tUCE Of DEATN C. CITY, TpWN, Ofl LOCATqN s. IS RESIDEN~E •~nant ~MSIDE CITY L~k1T51 ~pS~DE CITY LIMITS7 Cile. ~ YES MO ? YES NO I. N4ME OF not in AoiyU~, /kc ~htd eldrtu) d. 57REET ADORESS HCSPITAL OR IMS71TVTiON X. ;r~ 3. NAM[ OF fYrat ;4~[Qdle Latt DATE Mo~tA Da/ Y[n ~'''~°'D''"~> i3ICHOLAS D. SPI~RI ~"T« MARCH 1 1 6 5. SEl( 6. CpIOR OR RACE M~RRIED ~ NEVER MARFtED Q e. DATE OF liRTM 9. AGE (In /~tar~ 6 U~DER t iWt UripER ti IRS. 1~+f 6iltAfuy) N..N. D.M Hwr. Xiw, ~ 1~• M W wtoowro ? avoecFO :~;AY 16 1 61 p i~lnl ~ ~pq, USUAI OGtU1ATI0M (04e kind o/s'ork dont 10D. K1hD OF 6U51hE550R INDUSTRY ! I. DIRTMILMCE (57'~lt 0?/O~fi/7t lOU~I~/? 1. CITtZFr Oi w~MT COUt(TRYt •SSh p~t- [¢r+.n0+~do/eoarktpOh;7,esenlJrtlbt~) ¦"n•^t Oi~':v~R-OPF::i~17'0~ T~~'iiiJ ISLF of 2/~1I.TA :J~T. USA blaek ink f11THER~S N~ME 11. MOTMER'S MAiDEN NAME or t~p~rriter j}Q}Z;jIC SPY1'ERI rR:+?ICES AHBOTT IS. WAS DECEA$ED EVER IN U- 5. ARMEO FORCES~ 16. SpCtA~ SfCU111TY l10. 17. !MlORMA f f1aMATVR[ J~1S Sj~~ l.Crl ( Y~. we. r.kw~~wl 1IJ w+. w~v M4~ rt ~~arl ;~0 05 -28- 1 A~ti~~~ f~T. ?IFRGE F~. Funs Y a1 1!. C~VU OI DiATN (Ente+ m~tt on[ cswe ptr liqe frn (a), (b), ~eQ (t).) INTERVAL !lTWEEN i~RT I. DEATM W115 C~USEO AYa Olt$E7 AMp DUTM ~ueteflls IMMEDUTE CAVSE c.~ _ Gorcnar~- Ti:ro~bo~is tha eer- c~r~e.e. coneuroou, ~~.~r, ouc To (o) _ A~t C' o erot~C He3d't Disease •Sth the ~pp+~p rfs~ ~e ~ I o e R 1 aDove caax ~ re6lstr~r ~aie0 elk rnQer- ~E 70 (c) , ~'3~'• ~ j I~frw tauie lat. • 1 t h 1 tf 72 ~ PART II. OTMER SIGN~i1GI'!T COffdTI0M5 CONI'1lf~7TIrC TO OGTt~ aJi !qT REUIED TO TNE TER4fNAl Q6GS[ COIIOItq!1 GIYa1 iq /Mf I(~) ' . W ~S A OPSY hOUP• •f- F ~ RRFORMED7 te~ a.:+en ~ Saddle Embolus Re~uirinK Sur e - ~,~csp no0 or De for• 4~~ ~ DESCRI6E HOW INJURY OCCURRED. (£.rftf ndY~t oJfw}Y:r Ih PV( I M f PdJII D/It[nl l~J.) ' ¦stins •nr ~ ACC~6EN7 SUICIDE MOMIC~GE : _ - ~~poai- u ? ? ? - ~ ..i. . on of ' 2Qe. TiNe oF Hour MontA. Ds/. Ysm . . . ood]. V Ifl1URY •.7w. ~ : o p. ~w. _ w ~ 2~Jd. IMJIRY OCCUIIRED ZOt. ~I.~CE OF VaJVRY q„ Nt a eAOUt ~e+~e, 2DJ. C7TY, TOIYN. 011 LOGTION . COUNTY~ STATE WMILE A7 ~ IqT WIi1LE ~ Jarw1. Jatlorr. iP~eN, ejJltt AllO.. t!L) . . . WO?K AT ripRK ~ Z~ ~ I~tNnd~d th~ d~~Nd /rom ~ 2~ ~~6.~...~..~ , ro Beath •nd L~t saw him aJi.~ on _ 3/ ~ 7 ~ Ds~th xcurr~d ~t 1 7•~(~ 7 _ m on fhs d~t~ at~ted ~bw~; ~nd to the bs~t of m~ kno+l~d/s, /torn ths uue~t st~tsd. A11 lta~• ~y Y~a~.rV~ (ptprtto/lUld 226. AGL~RE55 72t, ~ATESIGMEO •r• Lo De eo~plsts « ,~onald R. LaPlatne - b10 P:. 7th. St. 2 6 aCCUPatl. ~ BURIAI.CREM~TqN. ].Yj OATE Zk NAMEOrCEME7ERY0RCREMIITOAY j.3Q,LOCATION(CitY.lOec+~.oi[v4n1~) (Slaf[) RF~bYAI (SptCIJT1 ` A -2 --6' ~T. PIERCE C~'~~~TFpX FT. PIFRCE, ~'I.ORID:; V. 9. ~ E 12 j~, FUNER/,L DIR t OR ~5 SIGNATUNE A AES ? IS. DATE RECD. !Y LOCAL REG. 26. REGISTRAR'S SIGNATURE a~..ioae T 901 `i°. '7th. Sv.~ r ~'.ilton r~, 3aird Ft. Pierce ~'la. -26--b5 Anr,a :.eG D~nison ~.r. I hereby certify this to be a true •~d correct copy of the Lra ' Registrr~~ record on fik fn the St. luc~e County Ne:~l!h ~e~art- '~~~p C 0 Rp ~ C mbnt ~t Fort Pierce, Florlda. V! [l~ja ~ Q~~~ ~ K (Warning: Not v~!id un!ess raised seif c( th~ St. Lucia '~~Ct-~..C-l-~ Covnty Health Dep~riment ;s 3ff;xedJ , 65 ~'r~~ ~ 0 PI'1 2° Z 7 N. D. MILL~R, M. County Health Officer d~ local Ragistror v;;_ ~ C~, ' 'CIE ~l~`' `cRK . 1 t-~~~b ~ ~1.`"'1 ~~..c~ t• , r_,r;~ sm,~..- T. ~ L U ~ J T Y, Date De al Rcgistrar ~ ~~-~RIDA ~r~~~K ~~3 5~ . ~ .