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• ~ DEPARTMENT OF HEALTH i .
DMSION OF VITAL ~TATI3TIC8 ~~S~O
JAG7CBO1~Yn+i.R ~'LOAID~
N° 13910 D ' '
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CERTIFIED COPY OF DEATH CERTIFTCATE ;
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R~s~sT~~~o No.
1. rLACE OR DEATM CoDS No. USUAL RESIOi.P1CE twr~.• ~.anN ~tw~i u aruau~: ~~+M
couNTr s'~~ !<<NIM cowm- dT• 1.ri1~~.
cm ur .rw+. «n.ru. wu.. av~a c. tENGn~ oF c cir ~u «+.w a.s.e.k u.sw ..u. sv~aua - ~
u uU M~a) OR ~
tv°ww J acso Ilr ~ u.s ~'~u?w *owN Ft P ~ tR ss ~
r. FUII NAMF Of !It Mt 1~ M~lu~ ~r wutklr. s!~ Knst Wdr~w ~e NluM~) d. STREET tu n~a1. dn MntN~1 ~
Noun~ oa Rtrs~ni~~ Nisr~t~l. A°D1~u 3~! th~ i~nr ~ssf ~
INSTRUt101~
NAME OF ~ llfnt) (ltiAdl~) a Iiast) L DATE UM~ti) (D~v) lY~ar)
DEGEASED ~ ~TM ~R~
K ~?iht
R SEX COIOR OR RIICE 7• W! R~1NE~
DI~YOR~CiD ty~t~1 OATE OF ~IRTH t. w6~ip. ~ ia•.~
f RW11.[ MI11Tt ~1 q Alf~ 1M~
10~. USUAI OCCYfAT10Nlatw tu~e d M IOb. KINO OF tYSiNESS OR IN- 11. {ItTN1LA (Nw K hMS~ e~+rs) 1!. ~u_
N OF M/NAT f
~..t_
~t u w~ B e.u..q OsI~Kt ~~usTtY TTSRV! LL Yp.
~A~Is
1~. FATMER'f NAMi . K MOTHER'f MI~IOEt/ NAYE
WIl~M 1l~TK~~11.1~.~ 4 ~ -
is. wns oEC~?sEO ~N u. s.niw~ ~cES~ i~. socu?~ ucuun . n. INFORMANi'S S16NATURfi ' r, ~IM~•
17.~ .4~.•.•.••) lu e•~ «..w ««n1eN No. 47'! 0 ~ •
1~. CAUSE OP OEATH MEDICA[. CE~t FIGATION ~N*~~
E.e.* o.~s o.. ~o.. OISEASE OR CONDITION f~ASSl.~[ ~illt~N~ltr O~N~tIM AM• oN.~* ~ e~?,N
y~e li~ ter l~). DIRECTLY 1~/1~IN6 TO DEATH'~~~
ud (e)
- ~Enr c,~?uus Mwt~~ 1 A~ I MM s~IM 1~~
t~ ~~i/~i
~aw0. it~rbii ~tti~w~. p s*f. af+i*/DUE TO _
we? w~sr! lai~. ~ia~ b f?~ sM~s e~swr ~f.
utkew~~. Ks. /t ~wr • W ~ p11E 10 t ~ ~w~ Q~S~ ~w ~ ~s
tA~ 1l~nM~ t*iMU. «
eew~lio~tiww r i i~* pT1/E~ SS6ltINGWT CONpMCNS
es..~i t.st~. ~~;M, ~y a w arat4 Me ..e ~AA~ E~A ~1~OR~TMMA~ ~t ~
y ~ ~ 1~. A{fiOKY? i
1l~. DAiE OF O~~ H0. MAJOR FINDM{Gi OP OlERAi10N ~
t
rn ~ ~ ? +
l~wwbl lr«us) 210. /LACfe OF INJtTRY (es. 1~~~~wa 210 (CIiYORTOWN (C01:NiY) (nAtq ~
'I 21a. w~ M~4 tr~. (~twa. ~twrf. M~w~f.. ~a/ ~t ~L Mw ifli~Li
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' 11r. TIMi l~~! lD+a) t=~r/ 2l~. 111~URY OOCYRRiD `
OF f~lts~f Nt~Ot~ ,
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111s*sby cs~i/r e~ot I stesed~d t~t d.era.d hroa~ - i~ . ta - la_. e~ot i Joee ,o+r t11. d.cs.+sd 4
aliw ow 10 awd tlko! dtatll ooe~ared ot st tlu ~+~tta a~d ow t~s dott teatsd above. ~
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d2 1 V~TUIt~ (~v+~ ~e qw) !N• 21c. DA't~SIGNM ~
4is~e. Y, onrsN..~rr ~.o. R~~a~s~.~ f+~s.~~~ W?R F~ 19~s
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~w~~~ c~,?. ~w. a?n ruwE oF c~~Y o~ c~u?TO~nr iw. ~ocr+no+~ taa. K~a~ csw.~ ~
~~*~R~r[~~'~ MAR. ~ SJ1iM fWKAIiL M~~! f~wT P tAK fL+011 oA ~
a?n ~c~o r~r ~ocu w~srws s~au?TU~ x,. wNw~ a~u~croa~s s~a+nnr~t noc~ss 3
YAR 1!~' Q E? d at ~ f R
I HEREBy CEItTIF'Y that the foregoiag ia a trne copy of the certificate of death o~
x
WIIOt ~A~! MA~tMKMtp1Z ~
i'~led with the Division of Vital Statistica of the Department of Health of the City oi Jacl~sonviDe, Florida.
~
FILEO AND RECORDED
ST. LUCIE COUNTY. FLA.
=,,,~~;~,y~~F~ ~ , n oi Vital3tatistica
1'rbb • p ~
' APR 8 PN ~ ~ad ~~b~csibed betore me this the ffi~• •~d ~~_~...18
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C~ERK CIRCUI7 COURT N°~°ry p"b~sc S~e'°•~ Fl°'~d° i°"~' ;
My conrnisstow, txpirMs Oct. 1. 1956.
- bndsd by Mrrieoi .Surtty Ca of N. Y.
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