HomeMy WebLinkAbout1626 rA~s b~- iTATt .owren or Hw.~x CERTIFtCATE OF DEATH '
~ ~
eo~~s • BYRGU OR VITAL STATIfTlCf 1TATt FtL[ N0. ;
lea•I ~eC- - FL08IDA
ord rAen `B1RTN NO. RE6ISTRAR'6 NO. .7.•
prop~el~
e:ecuted 1. PLACE OF DEATH GOO[ N0. L USUAL RESIDENCE (i~~AKeu~du~aS I[laruc~taa:reude-~+nedR~ '
•nd ¦111 COUNiY _l STATE ~ 6. COUNiY ~~O)•
,~.~.a ' St. Lucie
ta p~r- b. CITY lu ~sY~ e.r.~~ IWU~ ma sIIS~L) e. LEN6TH OF e. CRY W~hw anww u.~u. ..u~ stt~W
¦~O~At OR - STAYtr ii.eH ~
rii•. TOwN F't. t'ie Ce '
I d' HOS?1TAl ORF (It rt 1~ MWUt ~ Iruta~w?. stn dnet W~sr ~slosaW ~ tit a~L ttw MeuMU
INSTITUTION
3. NAME OF a. tFiait) D. p[WdL) a(Lst) 1. DAT6 (YoatD) (DAS) (Y~ae) '
DECEASED p~TM
(7y~ o? Pristl J
S, Sp( ' OOIOt OR RA Z WIRRIED, NEYER IIARpED~ ~ DATE OF tIRiH A6E ~p v~uu ~~w n~~~sa a~ ru
WIDOWED, Dt110lCED ~p~fb) Wt ~4tituu) ~ D~s~ Rwes Yfa
~ ! t • I'18~.6 - ~
~t°l~ 10~. USUAIOCCUtAT10M~C:.~ ur d wi ~~b- K~ND Of WSINESS OR IN- 11. tlliHtLA t~tat~ ~r tws orrv! IL CITIZENOFWHAT
.1 t A p~ r- aw ar+.s wt ~t waus pt~ wr u s~un4 OYSTtY , GOUHTIYJ
¦~n~at C382' 6 6 + •
L-l+et !ok fA~~ ~E ~t ypTM~Y gj -
o~ .
erp~~rit~r na e u T.•
IS. WAS OECFASED IN U. S.AtM~ FOLCfSt 1~. SOCIAL SECURIiY D. INFO S16NATU~E ty~ j l[~rp2~] .^,li nton '
lTa. r. ~r ~trw) q[ M~1w wr ~r rb d ~n1c+) NO. - - ~
wocc~ss
Fun•r~l 1r. GA1lSE OF DEATH MEDICAL CERTIFICJITION ~N~arw~ ~nwcar
ai~•ecoe Eucer o.b ~ ~ ~~~E OR OONGIiION ~ ~+?TM
¦u.s iil• Da 1~a (1). DIRECTLY LrADING TO GEATF{'~a
ca• c~r- ~ (s)
cifieat• ~ ~V~
~sce ca• •tAt.d«s+~.e++K* DUETO (b
1 e e w 1 t~s swi~ N jrisl. ]/~rbii co~itiwa. i~ sari I~R~Y
aaeA as icsrt ~s~vs• riw b tis sMx aaw (s) atst-
r~sistrar u~~~, /t~ °I w+~+4~1 a+w DUE TO c
E ~ 1 t a f a? 3 tA~ diasss~, iajrrw .
~ ~ours •f- ~st+pu~ II. OTHER SI6NIFICANT CONOITIONS
ce~ d~stp Cow/itiOw~ s+owtn'Datisy to tA~ jtsfi ~St ~t ~
or betor• ~etats! W As liusx er eoaditiow c+r~siw Jsatl.
¦alclna ~w~ Ifa. DATE OF O~~ N6. W1JOR HNDtN6S OF OfERAT10N 30. AUTOKYl
dlsposf- • tres ? tto?
e ot
IPnD~WI l~s) 210. rLACEOF INJURY (w~.uK~MS 21p (CITTORTOWN (COUNTY) (STATE)
21a. wcctocwt ara. t~mrs. r+~a. ~ ws• w~.) u asv. wu ~IILLi
Acedt I d R L -
21d. TI?AE l~) 1D~v) (Tar) IBwrI 11~. INJUlY OGCUR~EO 21 . HOW OID INJY Y t
OF ? rnui~T ~oT~uU
INJURY ~eC 1 ~ ~oat ? aTnot[
t'dMbO~-~ ~:i~?:tr9 41o1~Ll.
n I hereby eerei/y ~ot I a~Eeaded ths deuosed hom__, ~9 to l,~~j~~, t3wt I last sau ehe dccensed
si1 ic•as Q(ive on l9 o~d thu! dtulA occurrcd nt~~~ om l a oasa mid on u~e dale slated abore.
a~e so D~ SIGNATURE (WSrw o: tlW) ub. ~?DD1lF3s 13o DATESf6NE0
eoaplet• t
•«o*•~•• ' a a ulos Coroner i~t 2 Box 12 Ft. Pierce ~ ec. 19 ~
2ta. ~ U R 1 A L, CREl~tM tlb. DATE _ Nc. NA6lE Oi CEI4ETERY Ot CRFMATOtY IId. LOCATION (Cit~, tows, or eoanb) (State)
riON, RE?lOYAL .
- u~ Dec. Yine Grove Ft. Pierce Fla.
DATE ~EC'D ~Y lOCJ1L RE6ISTRAR'S S16NATURE 25. WNERAL DIRECTORY 516NATYRE ADD1tES5
v.s.fsoo .f Ft. Pierce
- .
, • .
~.:.~i~~.
~ . , ' ~ ~ ~ ` ~ FILEO AND RECOROED
'~~}~r ' this. to !is a true and correct copy o# the trocsl ST. LUCIE COUNTY, FIA.
e~y ~i~Y.' RECORO V~R~F~ED
; a Repatnr's rsoord. o~ -fik i~ ths St. Lucie Coimty H4atth Depart-
ment at ~o~t Pieru, i1Kid+• ,
• , ~
(yysmip~i N~ ~v.ilid unless raised xai of the St. lucie fs 7~~` 3~ 8: 3 0
• Co~x~ty He~lth D~putrneM is affixed) ~
' ` ' ; , " -158'72S .
, . N. D. Mil?fR. M. D. itOGER i'OITRQS
. j,,,;. ~ Cou~ty Hea~ti, off;cer b tocal Repistru , CLERK CIRCUlT COURT
? - 6'7 ~ ~'~ZQ . .si~.a
p~» peputy Lota) Re9istrat _ y. .
°~ooK1~7 ~~1~ .
a:: - - . _ _ F ~
. ~ ~7