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t ~ 13 pe- «TAT[ ~owno or Hsw~.~+ CERTIFICATE OF DEATH ~
c o¦ e s • oUR[AY OF VRAL STATIfTIC/ 1TATt F16t N0.
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ord •S~p SI TM NO. R d15TQA1t•f NO.
o•r1 CoDt N0. USUAL RESIDENCE (w~s+auew~l~na Uwxaw~K~µ'nw"`
::.eus a PLACE OF DEATH ~~w~ ppy~
.~a .~ii cou?m _ a 3t. LuC~e
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Sn p~t- b. CIIY /U wW lW~ ~r~r Wa~.) e. LEN6TH OF s. CtiY q! we~~ wnar 11~N~. ~rW ~IIi~W
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P, ~ t. e 6 Yrs
d. FYtI NA?tE OF ~u.saM~tr.rlrVUt~+.sM~Mr~~'~~"~ ~ 1~
HOS?ITAI Ol N
INSTITYTION
7. NAME O!' a lness) 1(lliiiM) lLrt1 OAii (liwtY) (D~7) (Yeu)
. DECEASED in p~d??11 M ~1
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j, sp( 6.OOlOtOtRACi L WIDOWEO
DItlORCEDiI~~ L DATE OF qR1H ~ Iiiir ~DV~ Sir~~a~a~
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`"l~ IM. Yi1MlOCCY?AilONlmw tw d.ws Nk KIND OF ~USINESS OR IN- u. uan+nwcE i.w ...w~ ~s cm~+oFww?r
~ p•e- a.ers..a.t.wsus ~r? r w~r~u o11STtr OOYMtIft
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D1••k i~. rws~uaY ?uw K MOTHiRi MAlOEN NIW~
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~ a~a.w~r.~Yw./ lY7r..Iw••••••r.d.w.t~N tia erae
Pantr~l G?~ ~~ATM MEDICAL CERTIRIGlT10N ~rw ~
a t r~es~r Trqr ~eb w~+++t 1. DISEASE Ot CONDITIOt2 ~j TM
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i 1 o c. 1 u• .ur. •r*1. .i.. u w ab.r eaw (U .r.t-
wd u Aawt I~rn. .
! ~e6~~«~~ ••u•~».~1~~°~~"'~"'"'""''"` DUETO ~Ii rtension Glomerulonephriti
f . t c n f e 70 W ~ursw~ 's~s*f. M
~ hour• •f- awsb«~ rAi~~ pTHLi 516NIFIC~ANi CON01110NS Ch~ (f
c~ r d~ as ~ °f~0i Cw~itJ~w~ erwtn'M~iw! M t~+ l~a~
or b~t~r• *d"~e1 u W h~csK ~°°wi~taw
aa~cfw~ aa~ Ifa DATE OF O~ IM. YAJOI NNOtlfCS OF O?ERAiION 70. AUTOKYT
d1~DOi1- ~ ? NOl`3
t~oe
• trre.Wl ttir«~sl 21?. fIACE OF IN.IU~Y ~.o.1~.r.rs 210 (G1Y OtTOWN [~~Mn) ~~T~)
tla wcaowt w.~ Ma M.n. ru.i ~~1LC. rrI tt ~s~L ~aw iVLL
su~c~o~
21d TIME lYw1) Wvl 17~ qlwr/ 21~, IWiiIT OOCY~~D
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. 11uU~Y fO~t ? ~T~O~t ~
. ~t. 1 lknby esrtiJy elae I nuewded eAs deoeaasd ho+R~-b... to~~ 19~. tAae 1 Jwt aow tls decsaud
a~ i is•.s ofive n» M 1 aed tl~c! drntk oatirrtd at ' P u~ !At emrsa asd ow dls dats slaled abo~Y.
.r• s• 1~ SIGNATUR6 (D~sr~ K eiW) ~~~f
co~pl~t• a
Jose h r. Batsche M.D. 16 Ave A Ft ierce a 1
11~. t U R 1 A L, C~NM ~I?. DATE 14c. NAME OF C~ET~Y OR CtE~1ATOtY 1N. LOCATION (p4. M~~. ~r eweV) (Bt~td
i1ON'~u°r~a~"°41 11-19 Pine Grove Ft. Pierae Fla
~ DATfi acc~o nr ~oe~u ~e+mua~s s~ew?TUe~ ~s. wN~ aucrots s~ctu?TUtE ~oo~ss t
_1 _ Anna Lee Denison s.
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Re~istra'a noord on fl{~ in ths St. Luci~ Cour?ty liMlth D~pirt- o i~ ~
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