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CERTIFICATE OF DEATH
FLOSIDA
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1. KACt N MATH GOOt NO w/~ ~w[MMRx~(MArn
e' 0°l""r St. Lucie 66-XXX Florida
1. CITr, tOwM.011 tOCATR)M r. t! r1.ACt a OEATN t. Cttr, TOwM.011 tOCAT10N r• ~ RESIOEIIC[
IIISIOE cm uMlrn
Ft. Pierce -Rural RISR)E clTr uriT~-
TESp wo® Ft. Pierce -Rural TESO NDm
1. NAME Oi (-/MI blMPRrI, /itt r6W slartM/ r. tEMRtN Oi a. STRE[T ADDRESS ON A /ARMI
~*~esidence 77 MidW Rd. 'TAr N w Hidx Rd -White Cit rtsp Nom
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SEx tDloR oM RA[[ T MARRED REMER MARRtO pAtE os RN-TN SI ACE ( rr++ I vADal Tw voIR>r IEIt.
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Male White wloDwtop aroRCEO Jan. 12 1893
10•. IRIIAI 00[11rATgN ((Olrt th11 r/Mr-! a..r la. KMR) oB RIISRIESS oR RMMIlTRr i 1. RlRrwtAtE (Iftlr w /Mt1I• tMwf-I) a1Ma1 a wwt DpIRI1Rrr
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Groxer Fern Industry Stillmore, Georgia USA
. IAMBI wAME MOtNER3 MAIDEN RAM[
Stephen G. Green Lydia Jane Haggins
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11. gYEi M MATH IELk- MII ewr trrM Pa 11•t M (•). A). •MI (e).i IwIERTAt RETwEtll
016ET ANO DEATH
TART 1. DEATN wAS CAUSED RT•
wMEOaTE cAl11E q) MyoCa_ d~e~ Infarction__ --~----- -s-~'I1na
~.,iril.r, l~.e,, 01E to a) Auriculor Fibrillation __ _ 4 Y*.
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-AIIT N. OnB1 SItlR-KAIw OOAORIDIS ODMIIEtIww ro OiA1M Rlir NOr RtlAlq to fIE ROwNMM. aMysT CdlMtlow illlN w rfRt 1(e) /ERrORMEW
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~ ~. OESCRRIE IIOIR RIIIIRr OC1.1MIK0. laLflr RrMr r/hIf•r, b P'rt / M PIMP !/ N wet 11-)
ACCN1EwT SUICIDE NDMICIQ
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a01. Ruuwr occrwREO Ikr. t1.ACE or MuuRr Ir. _t1-1-w .r .nwt bwr.
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WORN At WORN
=I l •ttendel tM Iece•.eI /roan I , fo ~- 1- •wd f.at r•w ~ j~ a)ir• on _ - -
Dewth acerrndwt 9 = • • oI ow tM Iote •t•t•d.bre; •nd is tM be.f o/ sly Aws~Ndp. /rom tho uutw rt•tN.
» RNIMAtIIAx (DI/-n t- tRk1 m ADDwElS tlt. WTE SIGIEO
H.F. Watkins M•D Ft. Pierce Fla. 1- -62
21t. RleAwl. CA[YIIOIL Z1! OATt Zk. NAME Of CEMETEwr OR CREYATOIIr tl/. LOCATR7M (Girl. tew. e- tesr/p (~etf)
Bu'!~1°d'~('P"`~' Jan. 2, 19 White City Cemetery St. Lu de Count Fla
21 it1IE S SIGNI-t11RE ADDRESS !S. DATE RECD. M wCAA REC. . RtGISTRAR"S SNiNAtURE
Joseph W. Yates, Ft. Pierce, Fla. 1-9-62 Anna Lee Denison d. r.
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~ hereby oertkfy thb to ba • true geld aorroet ~D'1- dF tlla l,idiLEO AND RECORDED :., ;,~:,,,,,,,- .
.,LINTY. FLA. ,• ~'- '
Rpbtrars record op file M the St. tads Countp lieehh Diet-LU C I E C ,~ r f '-~ ,
nnpt .- fort Pi.roa. Florid.. - .L~~Ot3 ~ _ .. _ . ~ < .- : -
~Mlamkla Plot valid unless raised seal oaf Mle St. lads :•`•. `~._3 _ -
croupy, ltaehll Dep.rtlrLrlt is affixed.) ,r{] ~~~ 9 PM 3 : a '~ ~~r~s-.. .-- :-~-~
N. O. MIIIER, M. D. C ~~ ,• ,Rr` ' " ~ c~ r ~ :.~ ~,
- County He.ltll officer •i t+ocal Rplstrar , ., sr' i ; -- I~T r~ a ""' y ~ -' ~•~ : ~ -
RK Clr'.CU17 COURT .!.:~•:. ;~ - .~ ;~, ~-
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