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CERTIFICATE OF DEATH ~
• F L O 8 I D A ~*wn rh~.s No ' =
oIRTH NV. EGISTRAR•• NO. H A ~
bp ~~CtE OR DEATH coDt ko. i U'
sU ~L RESIDENCB ~w~as ra~ rwarow: ~
or
o t Tu e - ?~'lorida St Lucie
.n s. cin ~n ..w. «...~w u.u~ .m. wa.r.? a Lg16TH OF cm ar ..~.a .«.«.a m.m. .~w :v..,a
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Ft Ptarce
d d Wtt NAME Of ~u.ea~.~~r~ys~+..~w...~«.w.~ a sn~ ~v r~w . '
, NOSNTAI OR AppRESS
INfTITU7lON
d NAME OF (riat) p1Y~iL) a (Lrt1 ~ DATi (14~t~1 (D~t) (?Me)
> D DECEASED OF
W ~ ~ w ' r~ z OEi?M ~II
f-~ [ fE7I OOIOR Ol tACE 1. WRRIED, NE11ER W, i. WlTfi OF UtTH 1. A6E r ~ rw r ~+~n t~ ~a
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d IM. tfSUAI OCCU?ATION~otw tW a wet !Ik KlMD OF WflNgt OR Iii~ 11. NRTHKACi tstw a 1.ro .r.s? IL pT~
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1~. FAiHER'S NAMi K MOi1iEiY M/UDNI NAMi ~ ;
w.~ ~R wns oEC~sEO iM u. s.~w~ Fo~cesv rc. socu?~ s~cu ~ n. ~Nroe?~wn s+a+nru~ Mrs~__Pearl B~ Samuels ,
o a.~.?...~.., w,..a»•.~~a.~»w..~+w
e.. c.~?use oF o6?n~ Vec)~cu. ee~rnFicwnoN o~?N..~,~.ra
Q ~ Aft wb ~ 1. OISEASE OR CONWTION . ppM '
W~~ ~~!or (~1. U). OltEC11Y LEADIlIa TO OFAIIN~
W ~ ~ AIiTECE~ti CAUSQS
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„k wua A.ve 1•~•••. siM a W•i~ aw (i! .taa
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Z,q p e~ liw+~. iy~q?. N OUE i0 e
v.n' °TME" s'~"'HG""T °°"°'T'°"s Y ertensive, coronary arterios lerotic ~
a no ~ c..aur a~~ +.e'w~ M .
~~~o i~. a?tE oF ~ i~. wuot pNa~s of otrdu?nod x wurorsvt ; '
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~ ~ ~r.+..u~ a.wa~ :ir, n~?c~ oF ~wuer i.~. e K.... (cmr ot rorvN ~ccu++m tsT~ ;
~ 2I~. Att1utNT Y~~ he~ Ocrq. KtMt. ~ir 11/i• Ya~ if ~L M~M sDLLJ
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~ tlr. TIKi tft~W Wa1 /!rH lswel 21~. IN,IURY OCCY~ _
~ ~ IMIU~Y a ~IUA1 ~OT~fMIy .
~ fNt ~ wTrO~t D -
a ~ it. I~s:+eb~r eerii/y t~et t atte~dsd t~t d~osawd Jroin n'n 1, , to 10 lAat I la~t ~on tAs da~owsd
~ alirae o~e 1D a~d e~at deatl~ oocwr+sd~ p~ t~e
eowe
~ o~ !kt dale atated obove.
~ ~ 21~ SIGNA R . lD~w «e tlti~ ~Y. AODRESS ne. DATfi SICNEO .
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~ nW1. ~1011At ~EMA- ~IM. OIIT[ ~Ie. MAME OF CiMiTi~T OR CRF~IATORY 2N. ~ 110N (pp?. M+~. ~e ~ts) ls ~
# t~41 ` ~ ~
~ Dil1 ROCp ~Y ~a WiiilfTRAR'i i! _ x 01 SIW1ATYii ~
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FILEO AND RECOROEO ~ '
i I~erby ar~i~jr tht~ to b~ • tru~ and aorraet e~p~, af tM t,oe,~T. I.UCIE COUNTY. FIA. ;
Rpistt~'~ noo~d on fil~ in tM St. L~ud~ County Ff~atth D~pul. H F. C t~ t?~,~L~,
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f11MM ~t /Orf PiKp, fiorid~. ~ir~r ~
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