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HomeMy WebLinkAbout2292 1 _ ~ ~ ~24 F LED ANO RECORDED ~ ~ 185 ~ ST. LUCIE COUNTY. FLA. ~ iiFCOt~•'.' ~1~~iF1ED ~ 4 ~ _ 1g5024 f . CERT[FICATE OF ~'A~j 31 PM 12 1 ~ d~ FLOBIDA ~ fO` ~ .~rb ~ 4`LA~C~EmOF D8J1TH ~ coo~ Ka s wsii ?n G~..~~~ w cou~mr = ! k cmr ar ..w .....w L.w .w saaara a t~srn o~ a cmr ae .rr~. .n.w rw~ ..r. s~,.ra L~~' ' OR STAT W W~ N~r1 Ot 'g TOWM TOWN Q i ~ i NJI: N aiaE OF pf r~ rlw~Md es 1wMS1~. slw wMt ~r La~W L STREET qP ~ML dw Lrur1 ; 'INfT,IT{ITION ApD~t ~ ~ cecG.Ewseo • cr,~.u . w c~cwil.~ • ~ u..~~ a~Ti c~o.ia~ cnq~ a..~~ ; N • DiAiN ~ 4 ~ 'g 6 fDC COtAROwRACE 7.11ARRlEO. NEYEI WIRRIEO. DAii OF NRiM t. AC! r• ~ttu rawu~N ~ WIDQWED. DIYORCED pr,~rs) wt 1~i~ D~n Y~. ~ IOa YSIIAL OOCYtAT10N~p~w yN d IM. KII~ OF WfINEfi Ot IN• 11: pRTM/~ACi ~ ~ 1!. CfTIZEN OF WHI1T w. w~....~.r.~ ~r....,~.arw ousrer aourmr~ : ~ a ~wn+a~s war?+~a~s wrow w?~s , ~ 1L WAS DECfJ1SED IN~ Y. S.ARM~ FOlG~f 1~. SOCIAL fFCURITY 17. INFOWANi'i SI~NA?YRi . ~ W a............~ ars.,..~..•.~...w.r...iw Na J. irr'. Yates a+ ADDRgf - y Q1° cwusE oF od?ni ME'DICAL CERTIRICATION a.rarw~ .a.w~a ~ w.~ 6 OISEASi OR CONOITION ~~TM y~e ~s. bt tb1~ DIRi~CTI.Y LfiJ101NG TO DrA111' S ~ a~i . : /1tiiL+CFDdJT C/WS~f : ' ~?Ai~ Jwe w~t wMS DUi TO w N ~I~... «+i~ ...+iti..~ ua~ ,i.:., i wwA w~we !d~*R •iN a W si~ ea~r fsl ~ae- . ~ a~tiewi~. ~ /t ~wy ~I f~ ~w~4r~iw/ ~ww Irt ~ ~w3+!~ DUE TO c ~ er~s~~ •~~~~II.OiHERfICNINGINTCONDITIONS ~ ~ a~~ ~i' Gwiiti~ erwl~hliw~ b t~ i~st~ i~t ~wt " ~ ~ y a w Jt«... • ' ; Ifa. D~Aifi OF iri. MAJOI HNOtNGf OF O~ERATION 7f. AYTOKYt ! ro ? ro ~ ~ (is~MW) IMrM 2ik /LACE OF INJU~Y (wR.L~r~ewt IIC (CIiYORiOWN (OOYNiY) (STATnc 21~. weuenrr ~ tr~. twres. ~r wr...ral It aaL raa a~i~L i ~ ~YICIDi 21d. TI~ t1t~U ~ (~~1 ~f ilw IIi7UtY OOCU~ ~ vrnt~T «oTrnts { ~ - .ou a o ; ~ tt. 1 Lsnby oakjy e)~ae I atteedsd tJis deaaisd /ro~ 1?-c,~~ 1~ to Q-T7A , la,~.. ehar I ia~ aav 111e decmnrsd ~ ~ ativs on - - l~ and thot doath ouwred o1 • n~ (11s oorsa asd ow tJls date aeoted above. ~ ~ ~ t7a. SIGNATII E (D.~eM K tlW) 7~b. ADD~i nt. DiATfiSICNED f 24. ~ U R 1 A L C~FlIA- ~I?. DAii flc. NAYi OF CENEfERY OR.CREMATOtY ~li. WCATION (Oldr, ~ow~. w ~aab) (8tw) ~ ~ ~ iION ~IOYl1t (y~Iql _ - ~ C ~ ~ a?ti ucro rr ~ a~~w~~s s~aw?ru~ ~s. wMwLL ot s~au?nrRE noo~s ~c - N Y ~ ~ ~ rr. ~ ~ :Y. ~ : ~ b '~,-~//~f~:t•~1 ~ . COff1~ t~i /0 ~f • ir1M ifld C~OfI'AC? OD~~/ Of ttN IAC~1 e f . ~ t~~ • ~j.wt ? s Repistrds r~oorrJ on fib in ths St. lucN County H~alth Oepart •~`-~`'-s ~ ' . ~ j ~ _.t r?.!, . TZ.. . Y nrnt at fort Pi~a. Fb~d~. ~ ~ / ~ (1Namin~ Not va1W unless nised t~~l af tfi~ 51. tuci~ s~~~ 3 ~ ~ County H~slth p~putrrnnt h ~ffixed.) .j<L.. : ~ , i ~ t ' aa{ } N. D MlItER, M. 0. ~ ~ 4' t` - ' ~ . . . ~ . Courfly H~atfh Off'~ow'3 L+ocal Rpktnr - . , . , . _b~,~ y~:.~ , ~yA ~ l~ ` ! ~ • f } ~ ` • ! ' : . . . ' Da1~ R+e~istr+r ~ ~~-t?=_R~`+i.. ~ D~uty lron! .:~...,..._~..o;.~+:::. ~ i . . t 8R . { OOK P~E~~ } ~ f • - - - - - - - . ~ - - - - - ~ ~ - - - z .._~::~t.. '~~~;...~.~.,__._y.,_w_ _