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1'721.31 iN,~RYIAHD STAif DEPARTMfNT OF NEALTN f.~ DIViSlON OF VtTAI AFCCROS, 301 W. PRESTON STREET, BAITIMORE, MARYtAND 21201 iL tEttTifitATf OF DfATH - ' l~ . V ii. y 1. PiAtF Gf OEA1H t. USUAI RfS{DElKE (Whu~ dectosed 6wd, d est~Wtan: R~s~dea~ Et(on oanussion) iuL~AfY ~ STATE (6UNiT . ~ `u e ~,~i ~uutruwD y J~/ e:~~Y ro~;~ ;N o„r~ ~o?,~ c IENGTN Of SiAY IN IS caY oq ~ ~n o,,,~ ~o,~«~k r~uu M«.a a~+~ ~,~~URA~ ,;~give r.ca st ~ ~ /c~~ ~S ' ~ o W.'.: HOSPItAI OR WSTI1Uii0N (li not in hospito~, gne slreel oddras ' d iREEI ADDRESS ~ p~ A f~RM? ci ~ ~'ES ~ %0 T ~y 1"~ ~3 HahSE Of t lmt 4. OATE Month Doy rcor = OECEASED OF aC G. / v 1''~ a x~'a) ~ OEATK H . " S. SEx e. CO:Ge ~CF 7_ MI~tR~fD NFVEe MARR~ED DAfE OF BIRi 9. AGE (In yeon ~F u~~DfR 1 rE4R UKpER II MRS. ' IU WiD0Y4fD DNLRCFD ~ G , ~1 lAontM Ooys Mows Mi~ . SA:US~AiO(CUPaiqlNi ~~ndolworkdone IOb.KUtDOFBUSINESSqR i1.8utt??PUI(E(tou~apiS~aa.aforeigncowary) lt tmIENOfWMAi . " ~ a~3 ~;o~- ~r j~ ~~~::y~ . ` iNaisicr _ _ ,~,~tqy~ ' Q.~ - - ~ Gld ~ %r~ . ~3. fau~;s~+r~~ ' n~or~ k cuwt ~ --f . ~ ~ ~ ~ , • ~ ~ ~~-t~ ° 'S. 1Y~; ' L c1~i L`~ U: 1~?k.(D FORCES? Ib. SOCUII SECUt1iY N0. ll. ~OjtMANT Address - (Tes n:~~,:.vfu ,t . y~,e dntesdst~vK1 -•i • , ~ ~ ~ ~1~r~~' . o ~ i ' r,` ~.6 C/IUSE 4F bEATH ~[r.te+ ~ w~. co qr io~, lb). o~a 1~~) I\ifQlAl BE11YEtN ?ldtil :i,AitLyyl,S_(~lJSEB ` 0t15~td]i0D"t1iN ; iyu~E ~l~aivc.ffn ~'iLL•" ~ ~ ta ~ . . b.li 2 ~};~,.t.- j~ ~ '-.~,ri~.~•` . ~ ' M t1~fC~~i~L.a~ ~9i MRf{h90w• ^ !~If~~I , + ~ ' / / ~'~L G~/~~~ 3 ~~:e so ~mmed~otataui~ (o~, ~ ' ` + ' . ' DUE ~a ~ ~ ' , ~;cAqg~the~ndulyN~ c60st ~ • ~j - 'osr. _'~._.-;`r'*" l ,G'~T'L"/'iosccc=i'~•-Tl~ /~/Fi,~.t'%' .?%sci?t.c c"f ~'r ~ P/Jti'fL 6if1E~Z j~'iNJFKRYiCOM61T)OIiS COMtRIBUTItICiTO DEAiH YUT MOi REUiED i0 iHE iERAIiNAI DISEASE (ONDIitO.~ GIYEN IN PARi l~o) t9. ~~a 4u~J~sr -r-, - ~ - , . , PtCi(~i~AtE~? _c , - . _ • _ ~i ' ( _ 1". i, • ~ J TES Ai0 ~.i ~ ` J; k RtQD+.,`U WAS(klO,~RLY1~ O' - .1~., SCR18E FfOW WIURY OCCUfL2ED. (Enter naNn d w~wy n Part 1 w Pon 110l item 1/.1 t- ~ v ' t'ii (fl!tiR{E/?i:.'iG?UlUSE~E.f14~~ _ . ~ ~ ~ r.. rtbirr C1Cl1l fxlr4Mk)~t , ~~~"1Jc i:tdi y~F .MIA(~11~C DeY: Yw~.~ y 1Qi.pIWRT OCfURRED ZJe. PtACE Of iN1UC1f (Nome, f«cn ?0!. jC~'y or 1oMm) j(oontY; (ka'e) ~~a ~Q NotMlhde ~aruY.s~reet.oliice',~dg.,ek.) ~ • ~ ot wwk ? ~ ; ' r ~ I certify~ fFimi~(1} . I) atfended the deceosed f:om <<' ~ , 19_~•_s, to r , 19 ~ Y::i~t tij ~,~w} l~st . I ~ ~ :er, tke :'ecc~ ed.olive on 1_7 19~, and that deoth occurred aI~~M, from causes ond on tne ~i_;;e stated above_ , f 22_ : GNl.iu<i JT :10. OAT: )h~AtO ~ ~ ~ /•~~~r~- ' ~_'t," lID.. ~PHYS~ D~RE(f[1~ ? P~VS. L.~ t fi 'r"!c -tlf,;itG': f 2:S AQD SS - . • ~ F- •.i.fdt'iy;w,i V.~l~!/V _r- . _r- . } i i'a^cJ • :'i..ti~" ij~ Y_ iT ~lCli-l-:i/.;/i~c-~ t_ ':io .;.(REN:•:~~it;. 13b. ~AiE It1iRtOF 13c. NAMf p1 (tJdil[Rr QR (R[~1A10RY 23d iJ:Ai1JN (I~t~ a ia~r) ~(ounq~~ iSsa!~) ~ <~t: ,r~l(:r , ; . . ~ ;i:~ i:ion 12-30.-1~}67 ~cdar Ifill ~rer,~tor " Suitla~~ci ~d . rL".F~S.t u:~iCiGt ADDRfSS 150. Rf[0 BY RFGKiRAIf 2SD, CfGI)ICARS Sf~•N~Tt'C: ; ; ~K.r3cr'~ Sons, Ync. ~130 :li~c. "vc. N.~' ai~~~~f~~U A L~v~=; ~c~ ~•.~v~~_ _ ~=..~4~`_~__~_ FILED AND RECORDED' ST. LUCIE COUNTY. FLA. ~c mco ~E 1`72131 ~o 1[ICS4FI Legibilitp of writing, typing or , `y pM 13 ` printing unaatiafactory in thia 68 ~ ~ docua~ent ior microiilming. ROGC~ OITRAS • CI.ERK CiRCU1T COURT; ~~i7~ ~1~36