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- 1'?"9183
z ~ ~ s ee_ nwTS oowao o~ Mrw~a~» CERTIFlCATE OF DEATH
co~es • ~YRGU OF VIT/11, fTATIfTiC~ fTATt RIL[ NQ
1~g.1 FLOSIDA ~ry
ord •sea 81RTH NO. RtGIrTRAR•t NO. ~rr
p r o p~ r 1 y 1. /LACt O/ OtATN GODi NO. L YfYA ~
MOSMC[ (1?Yn f~wr~tFr; J~hwli~.w: tr:brr ~I.n ~in.r'v+) •
e:taut~i t.
.^a .~11 Saint Lucie ~
~
e. yt.e.~
~ n p~~- GTI. TOMfM.OR IOCATqN ~ t. K~U?CE O~ DE~TN t. pTY. TOMM.OR IACATION t. K RE5~0[NCE
- •~n~At INSIOE fITY Uf11T IM510E 7Y l1YlTit
f,,.. t~est Of Ft. Pierce .ES,_~ Fort P m ~o
I. NJ1ME OF (/IN! tw ~M~ih1.1~ Wtd ~1?t~) I. STR[E7 AOORESS
"°S"T,~ 4 8 North 1 th Street
~T~*~*~ Grove at Sneed & K R
3 w?r~ e? fint .ViN[e LsM oATE X~t1 DeI Yea
^ °ii;
M`;.:.+~ GEORGI~ S. ADDERI.Y o~`?TM
S. SEX i. tOCO~10111U1CE 7. YN1111ED IiEYERMARditO~ WTE OF HIITN A6E(I~I~rI X~Y~ 10~A Mwn~ M"~w.
Y(eitl
1 L. 2iale Negro ~,~op a,~„«, Mar. 15 1901 b~
p 1 a f a 1~ Ia. ~ATIOM lQi~t tiwl ~f wrt fwe 1~. KuW OF WSWESS OR urOUSTRT I I. bRTN~IACE (Sldt R~i?ef/R eN~lrt) 1 q71tp Of w~Ni QOUllillt/
.icn p•r- ~wtNw?li~Ihk.nni/reroM
~•T•p~ ~.~a~iore Lon Is
Dl~ck 1\k 1 iATMtR'S MAME 1~. MOTMEII'S M~WEN 11AME
W3113am Adderly ROSa T8 10 ~
li. SOCU1~ SEW~Iri 1q. 1~. iN ~ NiN~TYIf[ A/4tN
6 ~t~t~aJ A 421 N. 12th St Fort Pierce - Fla. +
. Fu n~ t~. i+?YS[ O? ~tATN (6~ter wl~ au taw pt? Jia~ (a). (a). a~~ (c).) 11(TE/1VAL /EiM[[N
~ C f i~ e t O! ?A~T l OEATM MAS CAYS[O ~Y: . ~T ~~TM
r~~. ~.,M~o,+?TC wisc c,~ STt~IICK BY LIGHTN~~t
- !
ce• e~r-
c~ r i e~ t• Anditi~wi. i/ pr. 1 011E TO t0)
¦ 3 t e t?t r~iN ~qv ~ N~ .
x o e. 1 ~r c~rar~•1•
rt~i~~rar +~~+q tk rufn- piE TO fc)
+s caiw 7~ 7~ ~M J~.
. O ~AI1T 1~ OT~A S~C~iKMt COMOIT4KS 00~7M«RMC 70 OGM Mft Ndr RWlEO W M iUtMwLL DaG3[ OOI~II~OM GMa M NMT 1(V _ MAS A OfSY
Gours •f- tERfORMEM
c~r d~atY s .
or E~t~r•
= rD.. ~ 200. ocsc.~ut Now wupr occu~nco. lE•to •~rrr• yiyw~ ts Art ! a Prt !I ytnw t!.)
••ti~ns ••7 noaocwr wK~a ~arKroE
ro
d~~po~t- V ~ O O He was standin under a alm tree w s s
tion •t
D o d~. TtrtE Of 1/~r Xwt~, D~e/. Yer
w 2:~+~ r~~- 6 68 b~1 bOlfi. Of ' ht g-
= IO/. ~NA~1111 OCCYMEO mf. ~IACE OF YtAlllr lt. iw ~r ~ly~l NAt. 2% C~TY. TO~IfIi. 011 IOCATION COYIITt ST~TE
NO~K AT IIOT~~~ l~s. /~Ua1. atrtt(. ~~cu d(I/.. d~.)
~ ~ ~ 1 Mi k' oY Ft P r S Fl;
~ I ~tand~d tM ~wwd /ro ~ I
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Ne(~y[. ~,f17 $l,~ ~@ •nd la~t a~r ~~m ~Iir~ on
a..~r~ «~,,...e.~ D. . A. ~ 2 O)D . n.. tM d~t~ st~t~d ~Ow~: ~nd fo tM bpt of m~ ~no~rbdN. /~om tA~ uua~a st~t~d_
A 1 1 1 tf/• ~ Ty (p/~N M fYlt) ?ffi. ADDIIESS ?Zt. OATE SYGNEO
•r* St. Lucie Co. Court ~14~~
~o.pi.e• a _ r' e .
L* ~ tY T10R MTE IS[. NAYE OF CEMEIER~ OII CREMATQpr j3/. ~p~T1pN (C~f~, fNlt. N tN~1f~) (&'~ftl
B"`~ Pir.e Grove Cemetery Fort Pierce~ Florida
.~.1 s i Z 21. su c s s~uTU ss . @T wrE ~cco. ~r wc~ Rca. ti. ISTMR^S SKMATYlIE
F~r.lYdO . ~ ~ S@ ti• u. 1 8
I her~aby qrtify fl?h 1o b~ a ttue and ooRed oopy af th~ Loca1
Regimars ~eoad on flt~ in the St. lucit County Haelth D~parf- FILEO AP~ D RECQRD E D
m~t at F~t•p;a~e, ~{orld.. ST. ~UCI£ COUNTY, FLA.
` ~.C !~D V~ IF.ED
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~~~rY&'„ai~ ~ .i' ~ ~ i'79183
'f:~'~~, .~-.M«?~ , .
~ S9 J!!N 5 PM Z. 35
t. ..~~a: o. MIItER, M. D.
' :County H~stth Offk~ d~ Loc~l Raylmar
- ' - - R(~:,~E~ r 0!TR:.S ~
` Cl.ERK ClRCIlfT COURT
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