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I~ . ~ WARNINO: h i~ i1Mpt N~cat~ Nda ahr ~~t~tat N~oro~ra~.
~ NVS'20112•~pOM-1•N •
~ t~oo c«~. e« soeri ~ COMMONWBALTH OF PaNNSYLVANIA
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t~ DE1'ARTMENT OR HEALTH ~ ~ 416 S 0
t.n;~.. S~.ool VtTAL STATISTfCs
LOCAL BSGIBTRAIt'S CERTIFICATION OF DEATH
` Reyisccrcd No. a~~.~~
Full Name
' of Deceaacd ...Y._..._ _ _ •
t . N ~ ~
j.iS11i2 ~
I~~~Ilii ~ ~ ~ G~f f41~
Pla« of ' ~
Death _ a~ Picnnsylvad~
1 Date oE Deat Sodal Secu~tty J.~.~~~.~~_~....Race.....
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Madtal Status . ` Sez-. --.-.-...Date oE
o«~~ . B~
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If Veteran. whlch War ...._.._.__._.___..Veteran's SeNal Na
MEDICAL CERTlFICATE [acnval Betareen
Part 1. t7eath was cansed bq: Oa~et and Dcath
, t / l
Immediatt Causc (a ~ ~ ;
~ ~ ~ •t
Due To (b1----•--- _
Due To (c) . • .~t
Part Il. OTHER SIGNIFI CONDITIONS: convl6utinp to death but re to the ' iate ca in
Part I (a)
Acdden~ Suicide or Homicide _.._~....._..___..._..._._.._._..._.~....___How did iajury occur `
Name and Tide of Person ~
Who Certified Cause of Dratl~ (M.D.. H~)
1 ~
Addrea~~~~.~+s-~- r---
sti..e
' This is to certif that tbe inEormatla~n here given correcdy copied from an origtoal u' te of death duly fikd w+ith mc
' as Local Reflistrar. ~ ori9inal certlEicatc wW be foravarded to Scate Viwl Statistics, H q. Pennsylvania for permaornt
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DoM of Inw et T~is GrHtioatio~ . ~
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FILED AND RECOROED
,`:T. LUCIE COUNTY, FL.:.
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1`7i`738 ~
'68 OCT 2 9 AM 10 : I 6
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RQGFr< i'017R4S
CLERK CiRCUIT COURT
sooK 74 PA~~
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