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t«nrroa., 3~.00! VITAL STATISTIGB `!O 72452fi
LOCAL REGISTItAR'S CESTIFICATION QF DEATH -
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Fuq Name
of Deceascd . '
Address ~ _ y/~ .y. l ^ ~ ~
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Place of ~
Deatlt ~ ~ - PtaasYlvaNs '
Date of Death ~T~./ ~--.-____Social Secarity Na ~l/~ ~ „Rart-~ ~
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f Marital Status ' z ..~__Date of Birth ~ u~~~ ~
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~ OccupaN[~~;7ZGLC1-If~ .(4~--.~sirtbplaoe
[E Veteran. w6ich ~War ---•---__..._.._..Vt~cran's Serial No. •
MEDtCAL CERTIFICATE - - Tneerval Bctwreen
Part I. Deat6 was caused bY~ Onset ead Desth
.
Immediate Ca~ue (a)___
Due To (b)------
~
Due To (c)_. ~
Part lI. 07'f-IER SIGNIFICANT CONDITIONS: caotrib~tiag to deadi-~ut not rdated W tbe immediaEe cause qiven io ;
Part I (a) ~
. ~ . ~
Accident. Su~cide or Homicide _ .How dld tnjur~i oaw
~
~ Name and Title of Persoa
~ Wbo Certified Ca?ise oE Death (M.D.. D.O.. Coroner) _ -
Addrcas......_.~. '
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'Ibis is oo cMif that d~e infamstiaa bce~e b correcdY c~~pied fru~ aa oriqfaat c Hcate oE deatb ~ly ftkd writh mc
as Locai Reqistrar. ~ oci9iaal ~LeA~d~ ~ ~ State Vital Statlstics. Elarrlsb~u9. PenaaYlvaaL for permaawt
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ST. LUCIE COUNTY. F A. ~
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ROGE?~ POITRA~. . l~~ -61 _ 19_
ERK CIRCUIT COURT 0i1''°''""'
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