HomeMy WebLinkAbout0181 ' ~ FI~EO AND RECOROED~ ~
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'68 JAN I 8 AMI 10 : 2 q
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CIERK CIRCUIT COURT
CERTIFICATE OF DEATH
FLOHIDA ~
91RTH NO. REGISTRAR•4 NO. ~ D
1. PLACE OF DE 7H c ~ No. 2. USUAL RESJDENCE ta~?K.a~srau.«t ulmucuuo.: .~e<u~xc,K.
COUNTY , Ct~C_._ ~ ~ _ ~ 3 STATE z s. couNnr l~, •
~ ~T '''Z-'~ `~~~~-L-L =
b. CIiY Gt sd~ anorw lWte, Rft~ YII6?L) c. 4ENGTH OF a Cl7Y (it wWG wefoe~q 11~1K Rtq sL'RaL?
TOWN J !h. ~.C-~ :C~~ ~ ' TOWN •
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d. W LL NAIdE OF l1t at la Owptw K urttw~M~, pw ~twt ~st«i or 1ouc1ep) d. nREET tu ~~t, s1w lowurl
IiOStl7AL OR w -~y~ ADDRESS ~ O
INSTRUTION / / [.~.'j~3Z~i ~Q ~
t~ NAME OF a t3 A 6. (Yi~idk) ~(~satJ 1. DATF ~ontD) (Ds~) (YKr)~
D~CEASED A - .
f T'bP+ w£rixtl L~_ f DEATH tQ~
S. SpC e _ CO R OR RAGE 7. ?AA~RIED, NEVEt 1dARRIED, t, pATE OF ~IRTH 1. A6E _s s¦.a. v ~.ei. t..n
S 1~W C~Y-V WIDOWEO,~OIYQRC lSaecW! j~ Lu ~~tww~ Dis~ Uow~ i us
' ~2 / • , .
~ I~a. USUAL OCGUMTI011~pin q,d ~„1 lOb. KIHD OF WSINESS DUST Y ~~~~r~CE « r«tk.,naeer~> ~ IL C1itZEN OF WHAT
I Siw Aurt~ rao~t ~t ~oAdK Ut~' wr 7t ntlt~Al f~ ~ ~ C~~UNi Y! t~
~ ~ . ~f . :a'e.J _.~~J'~+. ~ aJU C-t.-C~! ~ ' %,L._ s~ . 17.
19. FATHERY NA?tE . 14. MOTHERY 14AlDEN NAIAE
~ / i.-' • l t~¢J ~-t~t .sv C 1 A~D ~ t,dJ ~
; IS. WI1S OEGEAS' D E~ IN U. S.AW ED FORCES7 1~. SOCIAI SECURITY 17, INFOILtANTSSf6N/1TURE ~~~~0
ITM. ao~ ec wtQa.e/ (usr. t~ ~Vr~ee~w.t+a+k~> NO.
L~ ADORESS . ~4, / .z+ l
IR CAUSE OF OEATH MDDICAL~ERT/FIC/1TION ~ • ~Nnev~~ smrceti
E„~ ~b. L CISEASE OR CONDITION /
r ! l ONfCT AND CEAT1~
ico. r~ t.~. ce>. OIRECTLY LEADIN6 TO OEATH~~~ L~- c.~[.c~{%~c~_.P ,v
h .aa c~~ ; ~ .
. , , ' ~ t,~~.~;n~ ,
•Tiia los~ wot we+a. DUE TO ( - f - ) /~-~1-1._ ~
tks ~wde o1 l~riwy. N~?3ii eoaditiow+. tl asy.I~~*O .
' areA u w~u! Jsihre. siw N tA~ sbon oaw (a) au~ Ln :
extAe..ia ata It see~u i~D W~*~*6~+~D ~
1
j td. disraa~ ir.j+try, o? DUE TO (c ~
~ cowy::ratioa r k i e A OiHER 516NIFICANT GONOITIONS
;~~d Cowditiw~~ cuwtri6~tiwy to tAt dntA irt wot ~
rrtaMd to tlee tisraae ~r eowdition eaK.~np dcatk.
~ t9a. DATE OF OPERA- Itb. MAJOl FINOtN6S OF 01ERATION 20. wUiOfSY7
E TION ~-7
h res U Ho L~
li`.~oo.atr) lsi,~e~ts) 21b. tLACE OF INJUIIf (~_L„ I40[aWu[ 2~c. (CITYORTOWN (COUNTY) (SiATE)
II~. ACCIDEaT ~ 1~ f . atrnel. a3c~ O1,1L...Mn/ ]t ival, suta 1tl;FL~LI j'/ •
~ SUICIDE ~ r r ~~f..'Y ~ - ~ ' ` ~ .
MOMI ` ~ .{~CUiC ~ I.~K. r•~'
( ; • ~F 8~11 ~i . i
2td. TiME (3tootb) tlht> eY~+r) IHa~d II~, INJU~Y OCCURRE~ 31i:
H W,DO Ip INJUqr OCCURI
i 1NJUAY S~ l~y~ *w~~t~rO MOT1~Nlt[~ ~ i C ~ ~ 4 ~ J
- f//~ YOD[ 6T1~OY[ ~:A7'.: '_L i'-tr~.'(~
r~. I)ureby ur(i/y ilwt I altended the deceased Jrom l-~ 19~L, to 19,~, tJtat I ladt aa~o 1he ~'c*cascd ;
r.lrre on~a 19~~, and Utnl derttA occurrcd nf ~n., frnm the cavsea and nn the da/e alafed abne•e. {
n+. SIGNA7UF;E ~ (DeYm or titie) 21b. ADDAESS j ~ , ~ 23c. DA:ESIGNcD ~
4_ / • ~ ' V t~I.~~r...t i ~ ~ ~.~i` ' ~ 4 t.a~./~ ~~'Q/ 1 ~ ^ ~
; 23a. i U R 1 A L, GREMA-`2tb. DATE 2k. KAME 6F GEMETERY OR CAEMAiORY `i 2<d. LOCATION (CitT, to~ro, or couatT) (Slnte)
;;TiON, RElAOYAL 15ta14) } ( ' - ' J % ,
; , . , i 7- 3 - 9 1 ~t. . . ~ , - _ -Lc.. I f .~.c.e-, z :
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i OAiE„ REC'D ~Y LOCAL AE6)ST ~'S S16NATURF 1S. PU4ERA4D:lECTOA'S 516 TURE ADDIIESS
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~'t~i~~ ~OO= a:ftue anb carect copy of the Local ;
Reg~alr~t~s tetord ori ~il~n~,lFys.St. lucie County Health Depart- ;
ment a~t j~~P(erd~; ~lorida:
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~"~VI/atning: Not ~rali~ u~+les~ raised seal of the St. Lucie ~
CoyqtX; He~lt~ Oe~partment is affixed.) ~
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~ ~ ~ N.,-D .'INtItER M. D. ~
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_ ~i~' ~ ~ !Z ~ ~(bynty Health Officer E~ local Registrar '
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prf~ Deputy Loce) Registror a• r- -
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