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THIS IS TO CERTIFY THAT THE FOLIOWING IS A TRUE COPY OF A RECORD FILT~OG~IN•7H DE'~Iwit~~t~
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Stute Regisl?ar o( l~rlal ShNr~lics Slal~ ('c?mmi~siunrr nj Ilroldi
WARNING: DO NOT ACCEPT THIS COPY UNLESS THE RAISED SEAL OF THE
STATE DEPARTMENT OF HEALTN IS AFFIXED H
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,NEW JERSEY STATE DEPARTMENT OF HEALTH
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• s?AC[s ~CE OF OEATN YSUAI RESIDENCE
; BELOW iOR (i?et~ ~eceyeJ li•d. 11 iu~itu~iN; nside~e~ belwe
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STAY (h tri~ ~I~e~) BOROUGH ? STA~~4 t~4 plae~)
BoROUCx o ~ro~nse~ 0~ So. 01`QTtge t,~rs.
TO~NSHIP Q So. Orange 33 yrs.
FULL flA]IE OF (11 Nt i~ ~os?iul ~t ir~k~ti~. ~i~~ aren +/~rew w e. STRFET
NOSPITAL OR Y1 I~cutM) ADDAE55 `~71 Fy-ankl in Place
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' NAME OF 1. DATE
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Dcnth occurrt ~n. o+~ fAe date atated nLove; and to tks btat oJ ~r?y knowiedge, /ro~w tAs caraef afnted.
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~ Fi~EO arvo RECOROED'
~ ST. LUCIE COUNTY. FLA.
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- 192124
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BOOK 18~ fACE
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