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FIlEO AND RECORDED! ~
Si. LUCIE ~OUNTY. Fl,q, ,
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190169 '
'70 FEB 20 PM 3:34
T r~ I S 1 NSTRUMENT PIIEPAREp OY
B. A. BITfAN. JR. ~-l-/~
.+~LES. BITTAN Cc GRIFFIN ~ ~
P. o. sox aoo r•.J':=i~ '"Ot`H.~S
:T P~ERCE, fLOR10A,9460 DEATH CERTIFICATE OF JEAN SAMPLE ~L~RK ~I;CUtT COURT i
~ also known as ~
EUGENE SAMPLE ~
- - -
_ .
IN RE: Lots 17, 18 and 19, Block 5, TUCKER TERRACE, Plat
Book 4, page 54; Lot 20, Block 4, ELDORADO SUBDI-
VISION, Plat Book 8, page 2; and Lots 3 and 4, .
Block 4, Re-Plat of SURFSIDE PLAZA, Unit 1, Plat
Book 8, page 27, all in the public records of St.
°i~ucie County, Florida. ~
• CERTIFtCATE OF DEATH
Cep~rl~ed ~I IIe~I1L u~ ReI~aF.ili4livt Ser~itYS lTAT~ FIL[ NO.
aveaoV oF ~~,~u~~ F L O R I D A 72
iY?f. O! ?ttNi IN ~'~~~R•~° . RCGI~TIIAR•t NO.
?tlMANtNT INK ~E~p_NAME ~~~si ~,ee,~ usr
~~O~` ~ , SE)[ pAiE Of pEwM 1 rOMiM, *tu ~
.smur+oas , ,~pN SA,~:PLE : Male ~ Febxuar S 1970
RwCE r.~n. wtow. urucu+ uw~ar, wGE-usr u.w~ ~ n.~ wme~ i w~ D~w1i=E Oi HR1M ~..ww~. COUNi11 Of DEwTN , ~
tu. ~ crr waa.r ~ ~ws ~ .os. wn ~ows .u..
, . ~Vhite ~,75 ~ k ~.Oct.B 1894 St. Lucie
C(1t. TOWN. OR lOGT10H Oi OEATN +.s.se <m ir.ws ?105?fiµ Ot OMER MSTIM - ~w wt w enw~, c~rt ur~r u.s ..wu~ ~
snan ~es w wo
n Fort Pierce Yes Fort Pierce Meruorial Hospital
ST~TE Oi MtM ~ r MOt w ~.s.•., w..e C1712EN Of WMAT COUNTtY ~ttlED, NEVE! wW1UED, SIR~?NG SrONSE ~r wt. oae r.wew wr ~
w~wnn~ WDOwED.WMOIICED~vetn~ •
~.~b~. ~ Indiana LTSA n~tarried Pauline Allen
.r~an eece.ae~ SOCULL SECW!!7 PUM~Et YSUAI O[Cl!?wtiON ~ a.e c.+s a.~o~a ow~e ewwo .wu w KwD Of WSR+ESS O~ 11~DIISTt1f
urt~. r O(~11~ ~
«CWUS y~ Wqt/Np W/~ Mw N~ln~{y 1
•~~.o~• ,:261-14~-4461 Farc~er Agriculture
~~we.~a rar wsw un ~rm SitEEi ~tW HN~t~E -
~ESIDENCE-SiAIE COIMiry CI111,
iOYrii. OR IOCwT1pN
~ ~aratrr h~ w w
,w. Rlorida ,N St. Lucie ek Ft . Pierce Yes i914 Fulton Drive
fAT11E!-NAME nyt ..bole ust MOTlIE!-MAIOEN NAME ~r~1 r00U u~s*
„ John Sa.~aple ~ar Ann Kirk
IMOWANT-NAMf MA~WG ADORESS ~sntn Oe .~0., ts~ p q.rn, st~n. i+~
Pauli.ne A. Sam le ~n 1914 Fulton Drive Ft. Pierce R1a.33450
?wat otwm wns twusca Y: (fN7Ef Or4t ONE GUSF IEf LNE f0! (e1 (bl ~ l~ll ~t~~ w o+.~tr .w x.rM
r.ea~
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; coremows, u •.n,
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' f~~tIMO tw! YM~lh -
f l~IMO C~Yf! l~{T ~
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IAli q. R YKANi CONO(f10rtS: c ~wa c urwc ro u.+M ..o~ uuno ro c. o~n~ n. .ur ~ a~ ~ YES rl~~ nwo~wcs ton-
y ~n .w~ s~a~eo w. wtew..wa uwu
O~ ~l~~w
Y 1~ IA
~ ~~,+?~eyti ~~~T ~.owrw, w~, nu ~ MOW INJVlT OCCURRED ~ t~~ wHq p uuvn u~ ~u~ ~ w r.u n, mr e~ ~
€ KiOf~ _
RrK~rl
} ]D~ 71[ M. IW
S
fNxMr AT MIO~[ .?UCE OF MlAM~ .i •or. snen. ~.nw+, tOCAiION ~ u~te~ w~.r.~. .w.. un a~o.m, s?.n ~
f ~ snan ns q w ~ ow.ce ana.. nc. i srecu+ ~ ~
i
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~ URfMICATION- rO+~M Mt te~u .a.K wi •uu uo u~t~ a.~. w+Iwa~ ~un[ Ow ~ aoiw.~ +~lw w[- OEwT~f OCCYYtO •t a~e nwte, a+ we
~ ~ INI3KIAM: TO ~+~M O~t RY ~OO~ ~RN 0t~1~- IwOII~I R. Y+O, q D~f ~lSi
~ ~nlMOlO M! ~ r~ [MpwnlpGf. Oy!
S - ~7 2 -S- o S .o w,,..,~ ~..ry~
i T~. 3~CF~s10ItOr ~ fl~. ~ O 21c ~ •
~ CE[fYKAT~ON-r~EO~CAI E7IMrwEt OR COIONEt: w~~e us~s or i.e ww a w.a r.e oeuoa..~ `r.s r~o.~ar.~c[o w~e .
e..r.~.nw d ue we....oro. aw ..nsnc..~o... w.r w.+~o.~. .w+w w~ n.~ noV~ .
~ w.n. occwro w we ws u+o wa a ae uusea~ sr.na.
rn, M m M.
~ CERi1fIER-NAME ~nn w n..n SIGNw ' un a nu DwTE SIGNED ~..o+m. w~, ru~~
P.ussell L. Counts I-'. ll. •
~ MARMK ADORfSS-QRT~4t u~etl o w tm w wr~ • st tr ~
~ 1209 Delaz•rare :;~renke, Fort Pierce, F'lorida 4 0
~
~ sun~u. c~wna+. ~..ovu urr oa c~.utoer-.uMC ?ourwr+ u~ w,o.,. ,,.n
~snc...
~ ,a. Burial Hi 11 rest ~1P~io ' ~ ~ ~ F7 orida •
DATE ~.~o~ww. ~.r, w.u ~ WHEt~t 1tWrE-N~E wn0 ~DORESS ~ sr~en a u.o. rw.. em a wr... u•n, r~r ~
~ ,u. F 7 ,s.. Y F,~n~ra~ Ii~:.~e Rox 777 Ft. Pierce F1a.33450 j
~ OAIE ~EClIVtD ~1 IOCAI ~E61STU1t
Y. 5. f612 f ~eKS REGtSf S+Gwsru+tF
b a.v.147o rw F L^t1dT'V fi 1970 t
~
~ . _ _
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I heralyy oe+tifY thl: to be s true and conect copy of the tecai
= Registrars tecord on file in the St. lucie County H~a{th Depan- .
= ment at Fort Piette, Florida.
(1Marning: Not valid unless roised seaf of the St., tucie
• Counry Health Depanmont is affixed.) _
_ ~ ~ ' ' • :Y . ' '
N. D. MIItER, M. D. ' J- ' : ~ ~ -
Counry He Ith Officer'd. local Registrar _ - -
. ; , . . •
't'~' O 0 ~ J_;~~ . -
Dat~ Deputy Locsl Registror . - • . , •
t' . r •J ,S ~r• ' ~ . ,
' - ~ ~ • ' . 1 , - _
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~ ~ooK 183 PAGE 217 - . , r~. : s . ~
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