HomeMy WebLinkAbout0510 , ~S~ 5~3~ CERTIFICATE OF DEATH 1,1~s'r
F L O H I D A ~'*wTS ~u No.
~ • 3IRTH HO. Rt013TRAR•• NO. ~
I. PLACE OF DEATH CoDt NO. USUAL R681DENCB Iw~.+MewNU+.a ltwucww.=r«s+r~+wrw.
`couNn _;t L _ Florida . St. Luc~~ie~~ '
s. cm w..bw ...~ew uw,, .dt. sv,.Ta G lBlcn~ of 4 cmr cu .ww ....M+ u.w ..u. avs.L~ .
° 3 T~~+ To~+ Ft Pierce ~
~ ~ a Fuu t~w6.oF ar.K~.ww~.~.~anr?d..,a.rder.rrerw e. mtEEr cu ...L aw w~w !
~ _ ~ HOStITAlOI J?DDRfSt ~ i
INSTITUTION ~ • ~
~ D ~DECEASEO a (riot) ti. (I[idi1.) (Ld) L ~iE (ltaati) (Daf1 (l~ar)
w' o t~,• e Na h 0 1 2
~ ~ i. SEl( i. OOIOt OR ~ACi 7. ~~~N~~ ED, DJ1Tfi OF NtTM f. ~E t[~ )~b ~~Da~i Aiiei~•••~4a
• (~s1
0 0 1~! r 1
~ ~ 10~. USUAL OCCU?ATION(p.~ m~ d IOb. ICIND OF WSIN~i OR IN- 11. ~ItiM?LACi ~~qw ~r wn~s w~tes~ 1~. CiTIZEN OF WMAT
~ `~~`~`o~`~~~~ ~V F rid '~i ~S.A
~ a u. Fwni~ts K MOiHl~!'f lUUDB! NAIAi ~
y ~ T
i-i
cv{~ ~ ~s, w~s o~ o+ u. s.nw~ Fo~~ u. socu?~ stcutmr n. u+row~un s~au?ruaE,y~arv E. Jones
aa p, r. R~bw1 IIf ~ r, fIw Nf ~ rW d Mn1W ADDRESS ~
~
w,x t~. CAUSE OF DEwni MBDtCAL CERTIFICATION u~~v~ ~atwm
Hater oab o~a 1. DISEASE OR OONOITION oMS~r w~ orwrN
~.~i ~a a~it (~j toe Q). ~IRECT~Y LEADINC TO OfAiH'~~
, W ~ ~ 111f~ECEDB~R GOSES
rl~ia iw~ rt ~w DOi TO
w~.a. H~*o. r..ira ~.s~ U.~~.u~
4 ~.ei .a aarre /~n. s:M to W air.~ enw ( at~a
I ~~~t~.
I~~ ~+M fM w'i~r7p'y °~w+ trf. Dl1E TO e
~ ~ Q
z~-; o+wsliwtws r k i~ l II. OTHER S161iIF1CAlti CONORIONS
~7 yp ~ Gwiitiw~ etit~alstsl b t~ i~st~ ist ~wt
a u w ii.w. eww
Na. DAiE OF O~ Hb. MNOI HNDtNCf OF O~ERATIO!! . 20. At1TOKYt
~ ras ? no ? ;
~ W~~b) lbd4) 216~. /LACE OF IN,IURT (~s..b~r~w~t 11a (GfYOt10WN (COUNITI (ST~UFI ;
, 2Ia. wte~oo~T ~+w hs. t+w~rs. Ma~ ~w WR.1a) !t ~d. r~u iIISaL1 i
` tl w~c~os 1
3 Ld. TIOM~E (~iru1. RrM ~ 21~. IWU~Y OOCURRED 1 W 1 U t
~ M ~
~ INJURY ~ iout ? ~r~o~i ?
~ n. I hereby oerl:lr that I cetena~d el~e aeeearea ~roa~ ~-19- . la~, ~ 3-20- , t~2. thoc I fast ,aw c?~e d..coored E
• ~ " clive on 1 J m~d thot dca~1~ oocu~rcd ot m oet the ocusu and oa tl~e date rtcted cbove.
~ ~ tla. SIGNATURE (1~eM re tlW) ~1~ 21e. DATE 516NED
~Q ~ M~ e
~ H.. ~ U R 1 A L u~u. a~. own ~ur~i oF c~~nr oa ceauroer ~w. wcwn t~xa. m~.. ~.~v~ css.a~
na+, ~ov~i cawa~
# ' {
~ ow~ eECro rr ~~cisnnaY s~`rutu~ s. wNC-~?~ oia~croa~s s~cMwru~ noo~ss
~ r } `i ~
~
i
,1,'r~~ll//////-/~ii~i „ ^ ,
- a.~-.,~„ •
` i~ "0~ kie • true and corred oopy of the Loa! ~ • . <
~ r'" ~ U tfis. Sf. lucie County Htahh Oepart- _
. ~ . f1L~0 AND
• - ~ RECORD p'
-r_ . - _ `ialsed ~sl of rhe st. ~uc~e _ ST. LUCIE CO
. I ~ p~p~rtn+sr?t is affixed.) , RECORp VERIFI~di~•A.
='`;s~
' ` ~ ~ 'i } - ~Z~G~ln/" ~
.y,~.l o. t?~'_'~'-,a~~uu~. o. ~T ~Aly i 2
J.rc, • .j. ~ '4~Zowity Hoalth Officer ~ trocal Raqistrar ~ " ~ z 3
~ a._~•'. ,~C .
_ _ . .
~ ~ . . . ~ . _ Jig~~?
i.~/i ~ ~ ` ~ 1 ~ • A i
~ . r . C~RK CIRCUIT CO
URT
. - eooK 164 ~c~
_ -
_
. : ,
- :~-x -
..s:;~~: