HomeMy WebLinkAbout2283 ' CERTiFICATE OF DEATH 144287' }1z
f L O 8 I D A ~Twr~ Fu.t Ha
_ BtRTN NO. REGIBTRAR•8 NO.
1. PLACE OF DEATH Co~t No. 2. USUAL RESIDENCE tww.~+watt..d uuwuur:.«~a..e•~.an
w COUNrr r_ a. SiAii COU !~w?.
Lucie b~ l~ Florida "~t. "ucie
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p OR STAY lb tW Nw) OR
~ ~ TOWN - • TOWN rt',. Pierce
v d. FUII N/?lAE OF IU rt f~ tw~tat ~r trutrt~„ sM rtn~t wt~r R 4 SiIEET lu nr~l, stw 1tatM7
~ ~ HOS?ItAIOR ADORESS
~ INSTIMION , - j-; ~ J
~ ~ NAME OF (Fiest) r D. (Ytddb) m (I~t) 1. DA p(o~t6) (Da~) (7Gar)
DECEASED OF
W w~ fTyH ~r Pmt) r + z- : r DEAiH ::A~T 2(3 Zq ~2
~ a S. SEX L OOLOR O~ RACE 7. WtRIED, NEYEI ?IARlIED, OATE OF tIRiH 1. A6E~v w~¦ ~ tu~ w~¦~a~ ¦u
VYIDOWED, DIYOtCED leowb) ~.a ~mae~s) Do~ H.~~ l[t~
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7 lOa. USUAL OOCUMTION~pM mA d wA ~Ob. ~OND OF WSINESS OR IN- It. ~ItTH?LACi ~wq ~y~ • Ii CITIZEN OF WHAT
W ar A.e.s.m r..~1.s n[A «..l[ e.uw~ DUSTRY COUNT~Yt
~ w p, ~ • :s - U S . t~ .
a 13. FATFIER'S WW8 - K MOTHER'S MAIDFN NAMi
i
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~ v~ if. WAS D EO N U. S.ARNED FORGESt IL SECURIIY q. INF0t4ANT`S 516tUTUtE
~ a a.?,...~~....~ cu~..a....«a.w.~~ .T N°• ~o~ss ~ J.~. ~e:5er~'Z' r.
O ~ Y
C~. _v,~ ~ 1~. CAUSE OF GEATH MBDICAL CERTIFICATION • ~wruvw~ .mermr
v ga~ ~y, ~ 1. OISEASE Ot CONDITION onur No o~wn~
~~.ci a~si li~w~ tor (b). DIRbCTLY LEADIN6 TO DEATH~ r'; n - v a' ^ n@
I ~ 'd AtiiECF.DElfT C110SK
' 'k ~ •iai~ ~w+we...a DOi TO ( , a r
i ~ tJ1s w~~ ~1 Yeriti aw~fttfawS sss.Ol+~+~D
M r~ a W. r.~ he ar t di s e as e
~ u~ a~tAswi.. sta n..~a. w ~w~s~ri*O ea.. Ld.
z^ o ~~~M DUETO e
s A~ ~D~~~* ~ 11. OTHEt S16NIFICANi CONDITIONS
~ yp ~ Cowlitio~ erwb~iM te t~ d~sQ bst wet
~ nisbi te t~ liaww or towditiow nrais destL i' P~~ 'Tr
~ o Ita. DATE OF O?E N Hb. NAJOR NNDIN6S OF 01E1AT10N 30. AuiOKTt
~ ~ ~ ~t1 ? NO ? -
~ lProawbl (N~» 210. ?LACE OP INJUIIY (as., L~~ewt 21a (CIiY Ot TOWN (COUNiY) (STAT~
~ ~ 21~. wee~o~n Mr. 4~ aeaes. ~wK. ~a. wae. sa) u eQ.l. Mw sIIa~L
~ ~ V •YICIO[
~ 21d. TIOM~E ptw~q (DO) IT~r) !~1 Ii~. INJURY OCCURtEO 21 H G ~ 1 U R
~ ~ INJUIY ~ ~roaiT~ ~iioii ?
a ~ n I),ereby cer[~)y ehae I accendsd el,e deuased hov, ~ 19~2., co__~~.. 1e~.2., that 1 lase aa~e tha deceoaed
~ a~ alive on % 19 f snd tJ+at death oeeurred ot m rom the cowei and on ths date italtd above.
~ ~ 21a SIGNA RE (Dese~ or tltl~) • 736. ~1DDREiS 7~e. DAT~SI6HED
~ ~ 1/ m~ ? i. ~ - P r~t r ~ ~Q r~
t4~. t U R I A L, ClEMA. 21~. DATfi 2~e. NA?IE OF Ci~lIE7ERT OR CRE?IATORT 3W. LOGITION (ptt, tos~, or aa~4) IStw)
# iION,~EMOr
L:ur~a~41 :°a~ 0-1~" 2 i~t. Pierce Ce:~eterv F~ t'' r ~ .
DATE REC'D tY LOG1L tECIS1~Y SICNATURE 7S. WNERAL DIRECTOR'S S16NATURi ADDIESS
~ Y~ !J ~ S » r ! r 1' '
0 - - ' -
~ ! RECC~D VF,RIFIED ~
~ ~ .
1 he ~ c~tifY this to be a true and cornet copy of the ~oce1 F I L Q[V E C 0 0 E D a
~ ~ ~teqi~ers~ teoord_ on file in the St. lucie County Health Depsrt- ~ ~~~~3 0 0 K ,y
~ - hnent ~t.Fqrt Pje?te. Florid~. , G ~a,~~~ ~i
, -
. (y{/arn7nyrNot vatid untess rsised seal of the St. lucie ~
~ . County Health Department ~~~X~a '66 APR 7 AM 10 : 3 9 .
~ , ~ - ~ ~ 14428'7 x
: ~ ) : ! 1 N. ~i. MILLER, M. D. ,,.,-i CLERKc.°i
J County Health Offitar 3 Local Repistru R 0 G E R f J ~ r
~ ~ ~ ~ , ' ` , ST. LUCIE COUNTY. ~
~ ~ _3 - ~ L - (n (o C-~~ • ~ La~~.~.t~F t~i~~ FLORIDA
_ p~ peputy Loul Registrar d.,, `
~
BOOK
°R14z 477
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