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CERTIFtCATE OF DEATH
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1. PLACE OR DEATH coot No. i USUAL RE9IDENCE 1wr.~aK...wr..a uwuusw: ~w~
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H IN~ITUTION A~~ ~
~ NAME OF (~~+tl OtNiM) ~ (LrU DATi t1la~ti) (Das) IiMr)
A DECEASE~ ~ ~
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i. SEX L COLO~ OR CE L MAlR1E0, NEYEt MARpEO, DATE OF N~TH 1. A6Etb r~~ ~ nu s~~~n ~M
~ ~ WIDOWEO, p1YORC[O tA~h/ ~ w~s/ Wr~ Da~ t4.~ nM, ,
~ Ih. USUAL OCCU~ATIONtoM tIM d w~ ~N~ OF ~USINESS Ot IN- 11. ~IRiH CE tetw ~ I~n1n wus) IL CItIZEN OF MIlU1T '
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II. fATF1ER'S N/WE
is, wwz cEC~?sc-0 ~ N u. _~iwEO FoacE soci~~ sccu~irr n. iNFO~Y sioru?TUn .-t,iilton H. Aaird
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ADD~ESf
Q~ 1~. CAVSE OF DEw1H ME~ICAL CBRTIi=ICATION wrswvw ~e~w~a
p`~ ~ aw 1. DISfASE O! CONDITION eM~ n~?tM
vK x.. r.. c.~. ci~ECnr ~?aNe To oEwnr~.) e bral ~]nbolu f~"a $
~.g }~pertensive atreriosclerotic he
""~D~ ~"u~ ease ?
~ ~ tAt ~«1t ~I. Y~riiJ entlilio+u. rl ~1. P~tw/DUi TO ( .
u „M,~ ~~;k,~. a, n.,, Generaliaed arteriosclerosie
~ adA~wi~. ~tt. I! weawa iwI t~ s~rlt~~/ osw 6af.
tlle lir+~. twj~rp. ~r DUE i0 e
~ aw~lierti~w r A t e i 11. OTHE! SI6NIFiCANT CONDITIONS
GwJitt~wa a+swfrihfiw/ l~ tA~ lnfk MN ~t
'1 ?e4tei b !Fs ti~ra~e towlitiow l~triw ~lA. ~
' ~ H~. OATE OF O n~ IM. MAJOR FINDIN6S OF OrERATIOM 71. AYiOKYt ,
~ ~ 1rp ? wo
Inee.bb) IM~sI t16. IIACE OF INJUlY f~.r.. h K~eeu tla (CITr Ol 70WN (COYMiY) (ftATE)
~ ~ Zla. wee~oeNt M.~. hr~, br~.rs. Ke..t. ~w YWS.. ~a/ N~Y, M~a it1LL1
~ sv~c~o~
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ltd. il?1E IN~W) ~D~s1 Itwl IH~~/ tl~. IHJURr OOCUlREO 1.
~ OF w~~u ~t wt ~m?t _ _ '
~ INJU~~ ~ ¦e~~ ? ~t wo~[ ?
~ tt. 1 Acreby cerli/y ~M! I alfended Ihs dteeosed Jrmn la~, l0 1? ,~a_.5]. ~Aoe t tm~ ~Ite deaa,ed ~
~ alirt ~n~1],_ 19 and lhat dcalk oetvned al +n roiw el~s oowaca ond on !Ae date a~altd a6ove.
~ ~ tl+. SIGNATURE (De~rw ae tlW1 7~. s~~~
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~ Na. ~ U R 1 A l, CREMA- Nb. O=TE tlc. NAME OF CEYEtEIY OR CREMAiO~r LW. LOC~ATION (Qt/. Mw6 ar ao~~b) (~bMl i
noN~~r~ 14,~,r,~ Ft i
~ DAiE lEC'O ~Y LOCAI RE6151RAR'S 516NATURE ~i. WN~AL WRECTOR'f fICNATYRi ADD~L3: .
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~~1efl~/ Ceffi~/ 1f11l•~O 1f{!e a~ OOr~eCf GO(~/ Of ?~1R ~OCA)
Regishar},/Atord c~ry~File in the St. Lucie Counry H~alth DsMtt-
m~nt tiM''F~t ~ierye,
f ~t'cslda:
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~yy~ca~~: Not v.si~cl,u~+less raised aeal of tha St. lucis F~LEO AND RECORDED~
ST. LUCIE COUNTY, FIA:' '
~{eattl,: rtment is affixed. RE. IED !
~ ~ ~ ~Giu^W Dep° ~
' ~ ~ ` ~ r N. B` ~MIIIER, M. D. . . . . . . ' ~
_ . ~ : . - ~l . ' ,
_:t.; ~',F-- ' CAunty~ Health Officet 6 local Re9isnK t68 ~uH ` • y .
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; p~puly loul RsgisnM 0 G E P. ~OIT ;
~ : . CLERK CIRCUIT GOlit~i• ; i
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