HomeMy WebLinkAbout2457 167'044
FILED ANO RECOROEO ~
ST. ~UCIE COUNTY. FLA.
. R~ rni~`,r~t
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68 MAY I 3 AN I I. 0 9
16'7Q44
i:C "R i•OITR:+S
Re: Lot 14, Block 47, RIVER PARK 1~~K~RCUIT COURT
as per plat thereof recorded in Plat Book
11, page 31, public records of St. Lucie
County, Florida.
~e CONNEC?ICUT STATE DEPARTMENT OF HEALTH . i
Publie Healt6 Stati~ties Seetioa-Hartford. Conaectient U.S.A. ~
~
~ Certified Copy of Deatlt Record ~
t. lwcs a Dcnm: ~s1 sate ot oooaeet~ent s. Vsuw~ ttcsms~+cs ~ nswwso: ~s) s~ate Florida j ~
ll) Ce~nb te) Towe ~b) Coneb (e) 'Mwa (dl L Reidenee In.~dc r
t~indhem ~.lli 1 L4Cie ~ J~ Lj.l ?~Q • Cit7 or Bo~'out[b Limitic? 7 k
1A1 Nawe o[ HaoiW or imtiwtbn (e) Street NamDer Ye~ ~ No ~ (
I1! ~at in ~ AapiW or iastlWtio~ ~in &e+ed Na fl! euh1. ttre beatfoa) 140 SQZ`Ql'1~ta U2'~[ Yes. name City or
20 Center Street, D~?nielson FO~ Lucie, slorida B°~6
3. N~MS ar fFiest) (Middk) ll+~t) Sr+c~w~ Sscuetnc No~taa
~.r,~ George Henry Ia~bbins ~ 041-O1-2116
MEDICAL CERTIFlCATION t7~e w ~t)
PERSOHAL AND STATISTICAL PAR'~ICUI.AR3 . Cwuse or Dure (Sater onl~ oae eawe ver b~ (~1(el and(e)~
SQ S. R~Ct ~WSY NL~R UAYRY INT~tfAL
R ~ ? P~es I. Dswtp wws Cwvas Br:
Ri~E I white I 1~vmowso p ~ro~cao O txxsouts Cwuas ~a1 o.\~r~~~o
s. I. 11~ws~ woowt~ os Dnvx~a a~s 1[etmt N~~te or COI'01'1dl'y thl^O~bOSis Ds~1~ ,
~
wa. o. x~...~ N~rgery Hambley I
,
f. DAl~ M (I~[oatM) (D~P) <YMr) Dvs so
Dt~?TN Sept • ~ 19fj7 It~a'°~np~
rr`~°°`'6ieL (~p~p~~•y/
10. Dwa oe Buret Acs (in rears it ueder 1 yesr It n8der 1 dy ~ tO
~ abare aasc
Nlarch 14 xoow D.~. x«~~ x~.. c.~. ~u~
f ebe aaderb• Dus ro (e)
1895 72 ~ ;
11. BtsTNM.ncs (Ciqr or wwa) (State or toreisn awntr~) ~
f Pwsr II OrNSa Swxn~cwtass Coyrnnova Co+crauunxc y=, W~s
; t,~inchester, Near Hampahire ae DcnTx ~ue wor RsLAT[D TO TIiE T~RMINAb DI
E Coxan9H Gtrw tx PwRt I(a). ~~Y ~
It. Usu~u. OC..'1/twltoN (Gi~e kind ot aork doae darlu: mast o!
~orkin~ Hte e~en if retired) Ys ~N~
' ~bN31lq PiQ~ll"@ PI`OjlCt~ORf St z~. sv~cas xas~r.H: to coxwswxs xsros~rs, ~w lax n.
€ lD1 Ixwstatt oa B~stxw Name ot operation I(b) Date ~performe~
~ Thaat+~ g
~ li. (a) Wns Dca~srs ~ Vsrw?rT Yes or No ~ lb) T~HS or IxiveY
~ (lrl It ~a, si+e ~.ar Y6. (sl AeemswT Svtaus Honutns ~ Naw lfwetk. Dar. Yss~ '
Vnk o~ Shi ? ? ? m. ~
~ 1~. Nwx~ ~n~iam=n H. Robbins (e) INivaY Oceussso ~dl P~.~cz w INauar (~.p.. i+. ~..bort Aow~.
F (CiUr or to~n1 lState or lbreiso eoonerf) W6ife at Not Wbik 1~"'~ 1~~O1y ~trsst. o~ies 61d1., sta)
w` Winchester t~sain2 ~ak ~ at Work p
~ . 8~.~.,?R
711ice ~e1 CrrT. Towx. oa Locwnox Couxrr Srwn
li. Nwrc..
_ (Ciq or tora) lState or torei~o tonntry)
~ It. 8teturucs New Hauapshire (il xovr Iwiuar Occuasso-
/Bwts? wattrt el iwjnry it~ Ps+rt I
l~. Ixroa~~xYs Nw~s or Pert 11 ~l ietw ss.)
Marqery H. Rnbbins ts. I HSREBY CBRTiFY, t6at I attendal the deee~sed f~as ~
i
1!. ~00+ C~ww~rax ~te ~p~• 19_.~ 19 . to I! -
~eter7 or Creattoy Rl~t~s~ C~P_t~1+V~~ t~at 1 Lnt sa~ We dae~sed ali~re on 1!
r~ Wbrcester Mass. .~a ~ a~~e ~...,a e~ e..~ o«,~~a -~-67 ;
to. o~ Erw.xa n as.8~.~uts~ Lke~e avmb~ :~_P. __~m.
~ ~l~~itl C~ ~~~i~St ` 17~0 il. SKw~su~a ar Pxttauult
~i`~~liam ~.•',,~PiT13~ ~ t ~"""•t. D`.~. Lavius Robinson, ~.~M. D. Med. / ,
i
~ -
9 Hutchina St Deni~on 9/9/67 ~
~ ~aa~e.. ~ e sOn: : ~ ea~.~
~ 'PAIa CLATtF S . Rsctats~s •
~ _ k ~ r I ~ Marcella A. McMerriman .
a ~ ' ~ ~ , ~
~ I eertif~ t6at t4L~ ja i tsds t~aia~ript ~tif 't6s ieformation oo t6e deat6 record as recorded in thi~ o~ice. ~ +
. ,
n Ass't. 1 ~
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~ ~ttes~:'..1:.{. MA~s~~~kLl..:~:/~.~l.l~[~~~,~LL!/~.
.'.~.fe~l~~..... Resistrat of Vit~l Stwtistics
~ Sep~.~ 'i4 3:967 ~ Killingly
~ D.t~ ..................................................................Towra of................................ ,
~ NOT GOOD WITHOUT SEAL OF CERTIFYING OFF1CiAL
Form V.3. IbC
~452 ~
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