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HomeMy WebLinkAbout0817 ~ lCERTIF[CATE.OF DEATH ~ } 4. ~ . a •e7w~a fiATt FIL! ~ ` ` ~ i FJ..08IDA ~ 0 ~ B1RTN NO. REG STRAR'S NO. . 1. PLACE OR D TN 1O ` N~`': -"~y'-' j' a ST'AT~fr R~~~~~ Op~~y truwu~: e..w.c. o.t~~ oouNn ' , r~~, b. ~ lu ~uw uNtti ~dr.=USaid. ~ STA~46um4~~l..y a CO~ . Ui «rww 1W4. .ew ~tt~w - - ~ 70WN (TiY - ~ TOWN ~tia,/ - ~ ( ~ d. W LL NA11E OF rt e~ Y~IqI a truutlK dw ~aMt w lwtlwa J. STREEf tIt e.p~L ~w ~1 _ k HOS?ITAL Ot • ~ ADDRESS~~ _ , . `~C~ ~ IHSTIIUTION . ~.OC.c...R..~~ . , • ~ EC6/1SE0 ~ (F~) L• ( ) l~) ~ OF~ (/l~[o.eU (DV1 <Ye~cf _ . _ 'b+ ~r priwtl DEATH ~Si~C.lJ a . . i. SO( i. GOLOR OR lACi 7, YA~RIEO NEYER MARRIED ~ f. QAZE OF ~ltiN L ACE ~IS w¦~ nu ~~~u a~ ~a . WIOOYIt~.DI~?ORCEDj ) ~+na~v) L.rr ;n~n a..s ~[r " . ~ • / ~ ` . 10~. USUAL OCCU?ATIOIkOM tW d IOb. KIND OF WSINESS O! I!4 II. SItiHlLACfi ~ayr~ ~~Me wir~l , t, ~ IL CfTtZEt10F WH/~T. " 1 fMef~ ~rt K ~Atas DtiSTiY ~ . : ; UNT Yt . .l~ . - . Il FATHEI'S lIA14fi, ~ ~ - „t ~ • JL MOiHEYf f1A1DB1 f _ _ , _ . ~ .~t . y . s~sa' - ~ a ns ac i•~u. s.~iwEO roec~s~: K. sxui sicu Na. t7. IMFOWANTf t1iNATY~i • l~I 1V ° ADDiKf ~J?uSE oF cFJ11H . - . - - - - - - . M IC/?4 :CERTiFtC!?TION ~ : u,Ti„„~,,.,mi,~,w- • ~es aab• o....~ CISEASE OR CONhtTiON J ~ ~ - ~ - : ~ . . . oN.~r am. os~?xn ; ~ t.~. c~~. OIRbCTLY LfADINC TO DEI?TH~~~ : a~i (d . . _ . r.,,; ~ ; ~ AItTiCfD6itf CAUSg . . . . : . i - ~ ~[rriii cw~i:NwM. tl st6I~~1DU@ TO . . . , _ . - , wa1 ~s ~rt 1~+. riN q W ~Msr aw (s1 ~t- . . . . _ _ . ' ~dA~f~ ~ It ~ww~ a! t~ sw~rMs1 an~r 1~t. WE TO c ~itit-~.(-l.i~ . . . . . ~ W~iw~~K ; ~ r a • ~ II. OiHEt S16NIHGWT CON01tIONS . • _ • , , . , - , : > , , i:" • • - : ; ~ C~itiw~ aowpib~Nsl N Gs L~tA irt tr~ • , , . ! : N W lf~ew w a+n~iitiew i~atl f I!a DAIE OF OfERA- H~. 11AJOR HHOINCS OF OfE~ATION . . . . , . . ~ r.~_:..s:: .d<. . 70. A8i0ISY7 i . ~ , noN ~ ~ : rp ? No ? ! , ~ ~ (Pnwt~) t~nd4) tl?. llACE OF INJU~Y (a~-. f~ ~e aw ;Ic. ICITY OR?OMM - (COYNTY) . ~ - (STATp ~ ~ . ! 2I~. AGCIDOIT YM. fY~ tkNel. MeMf. ~Yi. ~ia1 U ne~L ~t~q i~TtlL/ ~ . ~ - ' . . . ~ NICID[ . r . ' _ . 'g :~a r~wE w...~ WM a«r? ca.., 21., nuuRlr occuRRED u R . i ~ nuci~r aoat+~~u . ' ~ INJUtY ~ ~pRi ? ar *oa[ ? , . ~ ' . ± " . ~ zZ I l~ersby 1+1Y; l a«endsd tlis deunred /roa?~ ~1 , to_1~~~5G~'..4 t9Zt. thot l.lwt aav the dceewed i: ~ ' olive ow~ 18 and tAat deatA oee+incd at rmn !Aa enusa and on tlls date ieetcd obove. - ~ 7L. SIC~NATURE or_ j, 23b. A ~FSS ~ 23c DATESI6NED' ~ r. A-- ~ iu . • . ~~~f.l~..t-f~ yY~~etJ /A?- a2. - # D ~ RHIO ~ C~EIrM LIb~. OATE • lk. NAr1E OF CEl/ETEtY Ot CLEYATOtY 24d. LOCATIOM ( . to~~. oe masV ) (Staa) , / - ~ - s o d~ ~ • ~.,,c~..~e.. ~ R6:C~ ~Y lOCJ1l REGI 'S SICNATU~fi : . . - NE1tAL OI OR'S fIG TYR6 . _ ~ . ~ • • ADO , „ ~ - ~-r.r 6/ 9 ~ o u~ - 7~hlit.t~ ~ w~ `~~i~.c-c1Z~ - - - . ~ _ _ . _ - - . . Ftl. .AjV ECD OED ~ . :1 _ _ . - . 1N. 900K ~ L ti.i~.b~c -c•e~My this ro be a t?~,e snd aorner eopy of ~~'~~C~~ ~ _ : • . ~+o~•r-,:r~ s~b ~n ~ s~. u,~. ca,~~,? H« ! 0 AM !0 : 40 - m~nt ~f-Ifoet, P+erce, Fbrida. ~ . : s. ,~l ~ ` : _ (Wamirgs.Not valid un~ess raissd seal'of th~ St. t ~~~`.tJ ~ j~.. CouM~? Hmslth Dspa~tmsnr is affixed.) ~0 G E i{ F'i.~ ~"F;.~ S. C L~ R K ~ - - t ~ - - ST. LUC1E CQtJMTY~ : ~ ' ~ . 1' N. D. M~IIER, M. FLORI(}A' •~?~::~-r~;,: ~ _ . . . . . _ K ~,,r . ~ . - . County r.eatth Off~cer 6 toal ReyFstr~t : • ~~S , _ i ~ .,.,r~. . - • ~ - • ~ ~ a- - a N - ~D~v ~,v , ~?,a, ~ ~ ~F ~ ~ - , , r~;'~ _ : : '.r:.T--'~*''~~ . ~ } ' ' ~ D~ D~puty Loul Rsaish~r . • ' . ,,,L~,,. . _r ~~'`~R , ~ y: - - • . , _ . 5 - ~~~z14D z ~ 34 . . ~ . V : . - _ E~,~"~'' z~. ~ ` X ~ _ ~s. ~ ~ - - ~ - . ~._~~a,:::~i;