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t~« ee- ~TATE .o~~o or Nr~?~n~ CER7IFICATE OF DEATH
co~es • BURGU OF YITAL fTAT1YTIGt 4TAT[ FIL[ NO. .
l~s•1 FLORIDA
ord ¦Na ~ BIRTN NO. REGISTRAR•S NO. - ~
properl~
ei~euted ~~~t ~uTM T COD6 NO. 2. YSYAt R[f1Y[Mtt(~~w.MrN1i~M ffirwwi.wr /~~fwwW~~Ww:r)
•ad tlll ~~N~ St• ++4Cie LL A2 STATE p- C011NT1~
e. ~~.e•a g • I' .
1 n pH- 1. CITr_ TONM.OR IOC~T1011 t. K K~CE Os DEATN t. CIT1. TOMf~. OR tOCAT1011 l. K IIESID[NCE
aip~~lt D~ INS~DE ITY LIMIT51 ~e~e 1MSIOE CITY LIYIT51
f 11 Fti 16I~@ YE~ ND ? IfESk] MO ?
I. NAME OF (IJM! h Ml~iffl. /iK ~btd dbtMl IENGTN OF 5Tl1EET AOOIIESS ON A FAIIN?
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T~*~ Ft. Pierce Hospital ~r . 513 N• 15~h • St • "ES p"° p
NAY[ 0/ ~U ~fi11lt LaN DAT[ XMA D~~ Ytp
oceus~o
M r~*'~ N.a tha Boone °f"T" Au st 2 1960
S. SEx COld1 OR ~AC[ 7. MARR~D MEYER YAl1~1E0 OATE OF NIITN AfiE (I~ j10~ r u+x~ ~ rw tPW[II N/M5.
td NtWt) Y.rb D.r. Nwn If:.. ~
~ i c• Female Ne I'a wtoowEOD DIMORCED OCt. 16, 1909 50 •
y 1~101 r IO~- USU~1L OCCIMATIOM (OYe WIk MK 100. KWCOF WSWESSOI~ IMDUSTIIY 11. WITMKACE I57dt ~ fir[Ip tw~f?Il IZ. CITVEN Oi ~/M~T COIMiw1t
• t t! y~ r- Iu' .~wt N artial Mk. ~w il ntvd) ~
¦~n~wt . ~~aestic House Work Florida U.S.A. ;
D1lOY !pt ~i FATNER'S MAME I~. MOTNEIIS YAWEN MAY[ ~
~,v•*•~~•~ Jordan G. Grant Lula Unknoirn
IS. 1MA5 OECEASED EYEII U1 U. S. ARMED F011CES1 ~i. socu~ sccuR~Tr w. i~. u~ro ~~~?T~~ John Boone '
1 Tr. r. M wlrwl UI w. Mr wr M I~Y~ r~wr1
: N~ ? Allrrn g Fi
Pun~r~I 1~. CAVf[ o[ATN (SrMa NII wu nwt p li~rpr (S). aR~ (cl.~ IMEIIVAL ~ETMEEN ~
d 1 r~ e t~ r ~AI1T L OEATM MAS CAYSED ~11: n pKET AND DEAT~ .
• u~ t f i l• IMMEDMTE CAYSE U) ~Yl ni[1T1$j'~( aV--~
S ~
tA• e~r-
c,rie.~. c..e~r~,,,s/..,, ouc To ~s) Cerebral T~rom ?'~eeks
• f tA tl• r~it1 Nt~t •u~ d~ .
1 o e• 1 ~Da~t ~sax l~~•
~t.ri,y t?r r.4.- } ' jJ
r~6fstrsr j
.it~l~ 73 11~M t~rse lrf. D~i TO (d a[ H
~ ME
O NIIT R OilEll S~C~K+Mf COpDtf1016 GOMfM~UI11~C TO OEA1M ~IR MOi REUTED 10 TME ifSYUML OIYAY ODIpITOM GME~ 1~ ?Mi 1(U - MIAS AUTOKY .
Louf• •f- F fE11FORMED7
c~r ~~~t\ ~ YES~ NO ?
o r fer• 1 t06. oEStwut Now uuu~r ot[uaR[o. (F.sra ~~v~ yn3vt ia Pvt I~r ~r1/I yitn tIJ
i ¦~k~ws u~ ~ ACCWEMT SY~C~O[ ~KIOE
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~ s• Twc ac Hwr X.~N. De~. Yt.r
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= 20/. INJUII~ OCCYRIIED mt. RACE Oi ItW11Y (t. ia v~wl l~~r. 7D/. G7Y. TOwM. OQ lOGT10M ODIINTY STATE
MMKE AT ~ NOT 1MRE ~ M~~. f~M~. K?[d. ~~tt OIN.. dt.) .
MIO~K A1 MOQK -7~-~~~
21. l~tt~nd~d tMd~ewa~d/ m Ul~@ 19 9 , to Aug• ~ndfut M~ A,'~a~ ~li~~on ~~~7~~'v
DNtA oceurnd ~f m oo th~ d~t~ ~t~t~d ~bo?~: ~nd to tM 6wt d m) ~no~NdN. /rom tb~ uuws ~f~t~d.
?11 lt~~• jj~ ili~uriwt (Dlt/?NMlN1~) 2?D. AOOrtESS ?7t. WTESiG11F0
•r• t0 1•
so.D~.e. . Melvin Wolkowsky, 806 Orange Ave. 9-1-60
r
•clYf~t~. ~~.~WT~ jk. ~uMEOFUYETER~ORCREMATORY ?3/. LOCATqN(GVl.tww.~?t~f~) (8~k) '
~`uria~°"~~ 9-It-60r ' Pine Grove Ce~ete Ft. Pierce Florida '
7. j 619 2~. NMEIUI OMIE W'S SIGNATYRE AOOIIESS . 25. G?TE RECO. ~Y IOCAL IlE6. REGKTItAIlS SIGIIATURE ;
a••.'°"s p.T. Stone Ft. Pierce Fla. - 9-3-~ Anna Lee Denison d.r.
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~ FILEO A`JD R . `''T'~~~.-•~ , '
~ ~CORDcD , ~
I hereby certify th{t to be a trus and oorrect oopy of ths loul ~-r. L U C I c C C U~: T Y. F L:. ~ f,'
~ Registtsrs record on file in the St. lucis County H~alth Depan- - - r~ . . ~ - . : . -
~ ~ t:r=~j-f~ . , `e''F , -
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me+~t at Cort Pierce, Fbrida. ~ ' ~
~ (Waming: Not valid unless raised seal of the St. tucie 18933g. '~~-'~~r-
~ Couniy Heehh Gpartment if affixed.) ~ F E~ 5 P~~ ~ Z' ~ i ~ +a '
~ _ • . .
~ , N. D. MIItER, M. D. ~ - `y,• `
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` County Hsalth Offiter'd~ L+ou! Reyfstrar t; • S i~L~'' ~ -
CLERK CEr=:!~UIT COURT , • ~ ~ ~ ~
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