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."a .1~1 O0~'r Saint Lucie (pLb- Florida O0~'TM Sall'!t Lucie
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••••.t Fort Pierce ~ u"~n' Fort Pierce u*r w+=*~ R
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O~S 14th St .
. ~a Easter Manor 1~'ursing Home ~
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~ 8ess Rocvena Bolton ~„M 2 28 1968
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.....s ~ousew~.re Pennsylvania United States
)l~et l~k 1 FATM[II'S IMYE ~ 1~. ~10TN[R^f W?tOEM IYtME
:,,:.:~c.~ ~ Rev. J. J. Imbrie blargaret Sharp
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I~one ~lil].iam W. Bo3ton 2610 S. 14th St., Ft. Pierce, ~Fla.
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• olkowsk M. D. Fort Pierce, Fla. 3-1-68
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~`r01"`S'r"~' 3/2/68 Hillcrest ~iemorial . Ft. Pierce Florida
r. s. ~ s i a s swu ts. aTC ~cca nr wcx ~ccer~~s
a.Y.io6a , i7~ti~ates~';°~`neral Home , • r
t. Pierce, Florid 3 _ ~-1- (Q ~
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; he~~bX osrtify this to hs•: trvs ~nd oo~rect oopy of ~hs t+ocs~ F~~ED ANO RECOROED' •
Regi}tr~s Fecord ~ filb`in'ths St. luci~ County H~alth DeparN ST. LUCIE ~OUNTY, FLb.
fl~ r~rr ~f~a~~~F
mRnf~at Forr ~Fieroe; Florid+: ~ n
~'(Wuning: Not vaiid;unt6st ~atsed seai of the St. Lucle ~6'S~8
w: co~~ ~•ff~a.~ '68 APR 5 PM ~ 3: I 9
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_ ) , N: C. MIIIER. M. D. ~~'Cia+7V"
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. ~ Q~r?ty Haalth Officer 3 t~oca! R~pistru f. .
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. c ' : . , ' • ; ~ CLERK CIRCUIT COl1RT
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