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• New Yuric Siwte Depart,uent of He.alth 1~?~~
O~/IC[ OF ~ITAL RiGOROt
D"a H°• ~'29~0 CERTIFICATE OF DEATH R.~~.~a N~313
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1. KAC! Of OEAiMi STATE Of NEW YORK 2. YSUAI RE:IDENCE (WMe~ i~oNw~ Nv~i 1f NdMiNau n~iiN» MlM~
a COUMIY a s s au iTATE ~I/ rk ~idMiN). .
T01MM lENG1M OF R COYNIY t 1'OMIN
~ Se etead c;na"v~
u'oµe Naesau Fle etead `
o em ae v~~uaE d tllY OR YIllAOE a..aa....~~. ~e. w.~..+. w.~ti~ ~
Slmont 5 years glmont C7 MO ~ ~
r. !lM~E Of (lf wN iw Ao+p~d M imtilvf~ee. Y~w dtiN ~dde~u ~r lu~lbw w SitEl~ . IS tEf10HKE ON fARM
°u'~,~ 210 Xarwick Road 210 1larwick Rd. ra ? wo P3
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a. n~ of - s. a?rE w.•+~~ co.,t a...~ ~
tiKM«?°.w~ 1l~i1~8 I~ONS oe°~»~ 8ept. 8t21, » 63 i
s. sac s. caoe oR u?ce su+ciE. ~~~c~. wioow~e. if w~eo~wt~ a w...f {
aroecEO t Nv.s.~e ~
Female ~fhite ( Marr~ec~ - c«~ w,h Michael Leon~e
9. DATE OF tlliN 10. AGE (In ywrs If UNDEt ! YEAt'If UNOER 2~ NRS. I1, {IRTM?tACE (S4N et fNdr1 oNiatry) I ~~MNAT ~
~ lad brtAdeyl ~ AAoMM I Oo>~ ~ Ilow, I IMiw. COIINTirt
5~ $a~em. M~se. v. B.l ~
1 a US Al OCCU?ATION (Giw kind of v~oek don~
dwino ww~~ of worki~y lih. I~b. IU!!D Of WS11tESf Ot 1
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u_ fwn+ s ts. Mon~Ers wuo[N '
c al Anna iKajocba
16. WAS p[CEASEp EVEt IH U.S. ED FORCE57 ~ 17. SOCIAI SECI{~ITY NO. 1L IN~ORMAFli'S NAME ~pp~~
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(~ea. no, w If yih wr a del~a of wnin) aI1~Cl iI~ ~Q
~~~no~ {120-22-6996 A.Christensen for~aues F.B:,
I!. CAUSE OF GEATM lfnrN ow~r a» caus~ en ~ 1'~) IN~EIVAI ~E7wEEM
?11~T 1. DEATH wA5 CAUSED ~r: p~SET ANp ptA1N
uw~ou?rE uus~ ca~ -_~ute cardiac ~ai~.lure ~
a.~?~.. ~
~ ouE to cb~ _-b.y~rtensive ~rteri~scleroti~ j
c+i.+.t•).,tefiny ~ ;
+M~+r~^~ ~ heart_~~€ase. ;
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z ?AR 11. OTMEI SIGNIf1~AMT tON01T10N5 CONtRIW1tNG TO DEATH WT NOi tEIATED WAtAYTOKY 1
O I TO illE iERM111A1 COHDITION G1VEN IN ?ARl !(a) -
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I~TL~TION~ ~
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f 7Sb. AME OF ESTMUSNMENT tEGISitATtON NO. 2bo. DATE IILEO tY tOCAI 2fb. fIGNA1UR! R[O
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~ ST. LUCIE COUNTY. FLQ.
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CLERK CIRCUIT COURT
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