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HomeMy WebLinkAbout1365 ~ - . ~ 19~965 _ ~ ~ • S . ; ~ , _ . _ _ - - . STATE QF NEW .~El~. 'Y' d,~ . . ao. ~ OFFICE OF REGiSTRAR OF VITAL ~TATlSTtCS ~ r. Z~ ~ _ . - ' _ - ~ - - - ~r ~ of --r _ - - , - . ' ~ ~ - - , 8ocors? Qc Yow.s~ a~i - Tbis is ro certi/y dws ~he fallowiaa is oomc~l~ oopied 4,oa:s reoord af ~ea~ i. sy of6ce. - ; ~ ~ IIAi~1E OF OECEASED ~ PL~CE Of dEA " OATE OF DEATN I ~ V~'~L~ ~ / . ~ ~ ~ ~ / ~~G9' . SOCtAL SECURIT7 NUMBER SEX COLOR M ITAL CONDlTION - DAT£ OF YIRTH A6E ~ ~ ~ . _ _ _ rws. wos. wrs - ~ -3 2 ~ p f~ J/ ~,t.~- ;~l~eit~,c,G _ - /b" /~o~ 61 - - ; . P1.I~CE OF BIRTM . - CA115 OF TH ~ I , ~ ; - f . i _ _ _ , . , _ ~ R...: . - - - . - SUPPI.E~AEMTAL !lfFOR ION IF DlATN O TO EXTE AL CAUSES ; ACCIDEJiT~ SUICIO~ OA~ HOIMIGIDE . . Ai1TE OF Ot~GI/RRENGL~ _ ~ Nrui/t , _ _ ~ w~ae o~c ~?aunr occua~ , . ~ emr-ew *ew ' _ . : eerstT srwrc _ q DID INJIIRY OCC1lit INiOR ABOU1' NOME. OM iARM~ IN tRWSTRUL PLACC. fN PtlOLIC PLACET ~ . . . wsart n~s os ~awcc ~ wHILE AT WORKt MEAMS OF IMJtIiIY - ~ NAME OF PERSOM IMMO CERTIFIm LAUSE OF OEItTN--- _ _ _ - - - - - AODRESS - . _ _ _ ~ ~ ~ ~ ~ ~ ` /y~ ; , ~ t ~ ~ - ~ ~ FILEO ANO R ORDED~ : ' ~ ' ST. LUCIE C~UNTY. FLA. ~ ~ ~ t?~ CO?C: VER:.FSFO ~ ~ 1~~~1~) • ~ Sepstrac oE Vial Sradadcs ~ ~ '~Q 10 p!~ f : 40 _t ` , ~ ~ ; ~ ~ ~?e~Eft ~ i~PAS • _ . ~ . Ka,~•~~~••~ RT:....... - s ~ : . Drroe o~f Iss~er~ ` R ~ ~oo~c ?~.Z36~ . _ ~ ~ _ . 9.N. fOiN _ ~ ci VtMSR •UiNSMtIlC CO.. (MC.. tll;IITOM~ Y~ J,. ~ ~ - . . ~ ~ ~~'xr s>i w"~~,e~~~',~'~.,~- 5~^ . ,.z~~~ -a.r a'~,s ; ~ y ,s - J c~"Y±~~?YFe ~as'.~:-~.~ r~.,tkd~'`'~~~~Cf` _ . h 5.,~:.wT ~~v~