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HomeMy WebLinkAbout3003 = - 1 Tn~: De- wTAT[ eowno w N~u.TM CERTIFICATE Or^ DEATH 1653~3U GovI~6 le~~l r~a- •UAEAU OF YITAL fTAT1Y77C~ ~ *TATE FIL[ NO. ~ ~a~-ST E FL08I.. A - - ord ~p~n ~ gtRTH NO. REGISTRAR'8 NO. 111 properl) 1. ?41Ct OF O[ATM C006 NO. 2. YfYA~ R[s10b/C[(IIa.nln.r.tqMt. f/:..aae...: R..~wrW~..~.:..:..) ~ e=~eut~d ~N~ a STATE 0. OOUMTY - ."a .l" St. Lucie 66-025 Florida St. i,ucie D. Plac.a 1 n p~r- 0. d7i?. TOwM. Wt tOC~TqN t_ ~S KACE OF OEATM t. dTY. TOMfM, ql LOCATIpN t. IS RES~DENCE .,e.se Ft. uaioE ~n uM~rs~ Ft. Pierce ~~Tr urirn . ri1.. Pierce res wp rES ?ap I. Iu~ME OF . U/~w~t nw ~M~it~t. /(~t ~Erat Nlrur) LENGTM Oi L STREET App11ESS • ~ QM A FAIIM7 Y6T~TUTION ri - ? Y lA , YES ? YQ~ .t. Pierce .4em. Hos ital ~~rs 18_0 Boston Ave. 7. ~c or Fb.e _ xiWt~ L.r 1. wrc uaw v.r rea ~7ysu.s?~v~.i++) u . ii rM Q 1 Sflf i. COIOR OII RACE MMR~EO ~ NEVER MARRIEO ~TE OF k~TN 9. AGE (l~ K~r~ r u+0[~ ~ ~W - R it Wti f~f OutW/) X..W ~.w x.w Y:.. 1~• rnooweo p avaeeco g ~ .10l ~ la. USUAI «~V?ATIOII (Ciu ti~I ~/ioM~ /Oat 10D. KINOOF WSIMESSOR 1MOUSTRY 11. ~tRT ~tr ~r /erei~s cw~[r~i 12. pi~ OF ~w1T COUKn1ri ¦ 1 t A p~ r- I oi~I ~wat y oartit/ d/re. arw i/ r~t'veQ ¦~T~AC W Dl~ok lwk ~j, ~ATNER'S NAME 1~. MOTNER' CtA10EN NAME or c~p~~rft~r ~ IS. 1MAS DECEASEO YEw IM U. S ARMEO fORCE51 16. SOCIAI 5[CURITY MO_ 17. IN~O t NCMATVR[ ~ ~r..........a....~ w.....:......~~.w.r...:..~ J.W. Yates,~, ~ A6lsru F • Fun~i~l 1~. iAYi[ O~ OiATN [6~l[?M/1 ~a~YRliwt~w (D). q/ (t).] • INTERYAL 6ETWECM ~ OI~S~T I~D OE/1TN dl~~tt0? ?AlITlOEATNMN?SGUSEO~Y: ~ uy xrs. + ¦wt fll• W~E~~ i tn• e~r- i tiffe~N ! • i t0 tA? Cowlitie~u. iJa~/. ~ DUE TO , mlid /~It ?u~ q ~ 1 o e• 1 aDat casu t u~fi+~/ t4 rR4r• ~ registr~r lliy nax fut. ~ T~ i • 1 t A 1 O 73 0 tAl1T 11. OTIE~ S~GIi1Wlf CONDITIOi6 CONIwIMJfYK i0 DEAM ~11T NOT 11[lAi[D 70 TM[ TGYt~f~l OISEASf CQNOIi10N GIY[U IM M11T I(~) . M~S AI:TOPSY E hourf •f- ?ERiORME01 ~ r t~r dutM 3 1rE5? NO : o r be for• i p(KRI~E MOW INJURr OCCURREO. (Enfp wofY?t N~t~jtt?I iA Ppf I M PYf II ift~ !f-) k a~kfoa aa~ ~ ACCtDEMT SUICtDE NpMK10E ~ d..oo~i- u O O U ~ er ~ ` 2Ot. T/ME OF !/w• X~at~, OrI. Yro _ ~ UUYRY n. ~ O D• ~ ~~1/. 1NJUIIY OCCURREO ?D[. KACE OF INJUNY if~ M 6~+OU! AO~1[. ID/. CITY. TOMM.OR LOGTIOM OOUNTY , . STATE ~ IMNlI.E AT ~ NOT YIfNILE ~ IVA. HdMI. K~td. O~Ct OfQ/.. d[.) ~ WOIIK AT MIONK ` jl. 2~ 3~l '2 Mr 3-.L`)- 2 ~ I~tNnd~d tM d~v~a~d /tom , to ~nd bst w~r h~~ ~Ii~~ on D~atA oeourr~d ~t 1~~ k• m on fh~ d~t~ ~t~t~d ~bor~; ~nd to th~ b~at o1 m~ Rno~l~d~~. /rom th~ uuwa at~t~d. ~ AIl lt~~s jj,~. fIClMTYII[ (DepttNtLW ZID. AODRE55 72[. DATESIGMEO •r~ ~to D• ~ ~o.r1ie•. L.t~. VanTilborg,M.L. 808 N. 7th. St.,~`t.Pierce, Fla 3-20-b2 ~ .cear~t~. ~ 23~. ltpwtt, CNErATqM, j30. pATE 23t. NAME OF CEMETEAY OR CRCMATORY 23/. LpCAT7pM (Glf/, lava. ~r tarit/) (ST~tt) rau ( n/pl ~uria~ i:ar. 17 1962 Ft.Pierce Cemetex^ Ft. Pierce, Florida ~ V. S. ~ 612 j4. FYMENAI DiRE OR'S S1WIATURE ADORESS 25. DATE RECD. 6Y LOCAL REG. 26• MEGtSTMR'S 51GNATI:RE ae..~cas Jose~h ~~i. Yates Ft.Pierce,Fla. 3-2tt-62 Anna Lee Denison, d.r. r: ~ . ~ , a ~ ~ - j -~~~-.C f~ ~ FI~EO AP~D RECORDED' ;3 ~ helel~y`'certify il~is to'•bd•s`Tri~e ana correct copy of the t,ocal ST. IUCIF CQU~lTY. FLA. Registrars reCOrd on •~ile~. i~he St..lucie Cou:?ty Health Depart- F~ ~ • ~ ~ ment at Fort, Pierce; F7onda~ ~ = 165380 (Warning: Not.,valid;unless raised seal of the Si. Lucie ~ ~ Courif,v Health~',`~epartment is affixed.) 68 ~ 2 Q PM ( 2• 2 Z ~ -;}:r;~ , ~ . ~ . . . • . ~ 'N. D. MILLER, M. D. , ~ County Health Officer 3 Local Registrar '~~~r ~'0' i R.:.S CLERK CIRCUIT COURT ~ f~l-~U ~~~~.r~~.ti~ L~-- d ~ ~ Dats Dep~ty total Registrar c~, . ~ ~ ~ - BOOK~ ~O PAGE2J09 - ~ ~ . - - - - ~s°- . . ~ ~3L ~ n r"wt-tT~`m'a-`-t _.~S'~se"n.~_ b ~:Y'rd