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sace ~ra ~ ae~m CERTIFICATE OF DEATH s~~ Fue x
Bareau ot Vitai statistics F L O 8I D R - N
L PI.AR.Z O i IIBIIAL ~i~Ci QT DZCEASm ~ .
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ac~IDt~ _ . t t~ n~.M~{ N a~ - ~
6ta N) Ccm?t~
(b) t~e~deec
g te) Cfb ( rlt~ not nt~brt) ~ N (e) pt? at ' ~t-[it.v`.
g ' .3 - .f ~°~`~dj~°"
't (e) xam~ a! 6a~pital ae ~ Streat ~
~ (i! not 1n Lapital ae m~tla4 str~at numbri ae Ic~tlm) Citlan d 7b~'d~n oo~mtr~1 ~-e-
a I.e~th o! stq: In Lo~pital c[ 7'~ oe a0
w At Dl~a a! . I! 7~. nam~ ootmReT
(SDed4 wl~ath~ mmt6s or dys)
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~ ~J. lt1IJ. NASR O!
~1~ ~j ~(y g~brao. i(b SeaQlb IaDI!'.AL C~tTIIICATION
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c7 L O~ 6tID~ ~~i N D~aTO 0! Detth: x0o j~,y
~y~~~ X vin~.. c 9+ e~c
~ 6s--LLW~/w~~ ~ tbbr ae IL I -cetti4 tLtt I atteoded tbs deoe
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O~~ 8 m~zrled, w aweQ ar dtraoed. at (ar) ~t last L~. attn • aod
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~ tLat deatn ooadred m tLa d~?bs o~d Lo dat d abors. Daratfon
f ~ rJ ~ f(b) A!'s o[ btu~nd at w1h~ 8 Imme~dlate cauce death
7. Bleth d~a a[
j ~ .~t ~ (mmtW (d~l?) :
f r°~, a w~.: :.us ~Lmfn. a.~. i! ~a.. thaa m. a.~ aw to
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~ b p (pb. town ar oama) te ae Locel~n ~ountq) (Includs peesoaoe,~ withia i months o~ deatl~ ~
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11. rndustrs ar 1Wo~ ena~nBs: .
'~r~' 11 N ~ t
s~can~to 2
~ l1 (fiin dats at oy~tl~on) a~IIoo~ld
6~ S
~ tLaistd~ta ` :
l< 1(afaen d ~4• 3
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~ It dNth ~ dus tio ~cbesn~l ~ 8D 1n tLe fullo~artn~: ;
1~. ~ntaemmtls 81~ ~ (t) (Prob~by) AeMdanf. raicsd4 Lamtelds (speM4) ~
~ 1! IaI (b) Date at oce~ureml+~ ~
17. HueLL tlan ae e~eoo~tl ~ (e) Wf~ dsd Wm7 oatat~~ ac tawn) (Camt~) (State) i
17 (a) Da ~ 17 (D) t+ ' (N D1d W~a7 oo~vr in ae ~bout Loma m Lr~, fa iod~i~l pt~osr '
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V. d. lfa ~ . m~~ (SD~4 t1De a~ D1aoe) i
Wef1s at wor (e) ad W~?
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1!. sn 1..ca18egtstr.r eN ' te s .
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~ 1 hsnby oKtify thb b b~ • trvs and oorred oopy of tM Local
~ Rpistrds record on fils in tt?s St. ltxl~ County H~a{th D~part
~ ~ILED AND RECORDED ~ • ~i :
~rnrq at Fo?t Pierce. Flattd~. S i. ~U C I E C 0 U NTY, FLa . ~ x
~ (Wamin~~ No/ vslid unleis raised t~~l of tFN St. luci~ _ ^ ~ ~ - ~ ~ . . ' jY ' / • n. i
~ ' . County Hsshh O~panm~nt is ~ffix~d.) - ~ . ` ' : x; 'j:'~~
~ 1s~33 ~ Y ~:.;:'t r,
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~ , N. o. MtItER, o. ?0 FEB 5 PM !2 : 09 s; :
CouMy H~aith Offiar'3 lAUI Rpistar ;
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~ pp~ p~pAy Loul RepistrK L R K ~ t R C U 1 T C 0 U RT , ;
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BooK1 2 214~ . ~ ;
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