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HomeMy WebLinkAbout0749 'v. ~ 1~2`~O~ ~ se~~ s.- sTwT~ .owuo or M~tx CERTIFICATE OF DEATH eo~~s ~ BURiAU OF VITAL iTATi*T1C~ lTATi f!L[ ti0. '•a•''•`- FL08IDA 5~ ord ~A~a BIRTH NO. REGISTRAR•s NO. prop~rl~ t. ~C[ OF K/?TN CODC NO. t YtYAI AtNYtNCt(~?V.rwr.t~ri l/i.wti.~ R.:br~?..~~:r;w) e:~eut~d OOUNTf a. ST~TE 1. O01lrit/ ~ad ~I11 ~lae~~ L' ~ , t. yr- s_ aTr. To+n~. oe wcwT~ e. a?ucc os ocen~ e, an. Tu+rM. oR wunai +s Rcs~ocNCe .as•.e 11410E C~TY UMITA u~a~oc atr uwirs~ til•. • ~ , res0 ~a~ ' ~ ? res0 w~ f. KAMf OF (/JfM tw ~Mtlf~. Iiiv N?RO! ~JfrtM) LEM6i1i Oi STIIEET ADDilE53 MOS/ITAL OII AY W 1~ CM A fMM1 ws1~TUTaM j R it' res p_. No p ' 3. tu?M[ 01 fbM Vitlft LMt 1. wTE 11[~+4 A~ Yro ocenuo ~ ~ ~'y""' Rolli Valentine Anke °EATM At; _ . S. sc~c i. ao~o~ oR iucc 7. y,u~~co ?~vc~ ruu~co a?rE ov wrn 9. ~cc U¦ rs... r uwa~ ~ ru. u.oc•:. w~s. l~d Oi?fW/) Mwa~ D~w Mwn Yw, ~ i s• Ma7,e White Mnoowco? avoacco De -lg 1 f 1~ 1 a l~ {0~. IISUAI OQCINATpM (Q1k 21Af yw?! {NS 1~. KY~DOi W3771E55011 Y/DU5711Y 11. tUlT/VLACF (.9'~!t MlNtfls twatr/) 1 ClilZk7! Oi ~/IMT OOIMIf1Y/ .isA P•r- IYriy~wtyw?W~dk.err~y.eti?ep ¦ae~nt F R . I llaek iwk (AT11EIl'S 11AYE 1~. YoTNEIl~S MAwEII N~rE Or E A ' Fanstina 21eFrcor:b IS- MJ1S OECEASED EYER MI U. S. AlIMEO iORCE51 16. SOCIAL SECYRITY Iq. 1). !N?O ~ sIpMATYw[ • R~ ~e~ 11w. r. ~ ~lvwl If/ M~. w~ wr ~/we rwrl T A(6tq Pun~r~l (f. iAYft M O~ATN [A~ftr N(/ Ms ~NU DAliat f°~ (A). a~! (r).) ItrtERVAI lE7utEEN d 1 r~ e te T ~~RT L OEATN wA5 GYSED ~II: OitSET 1YID pEATM .~.s ni• IMMfOtAT[ CAYSE carcirc~a Slnn=rh tA. e.r- sitieac• Csatiri~iu.i/p/. p~ Tp ~itA tA• r.?in1 ~,qt ?w'~ N 1 o e• 1 ~De~t t~tat r~aistrar K~ ~ r~- p~ TO (c) ~itein 7~ z MM nur fyt. lour f- ~ ?MT {L OT~Et SIGMIfKAIff ap01iq14 ppNlqplfK rp p[wTM ~IT Npi REUhp Tp nq iGryy~ pISFASE (pq~pN ~ry~ N?~i 1(~1 . WAS AUTOPSY f - N~ d~~t4 ~ - rfltFORMEO7 - er O~rer• ~ ~ YES ? h0 ¦~kfwj aO~ ACCIDEIIT SUICIDE MOMIt10E ~oD. ocsca~ wow uuu~voccuw~o. !E~uo wwvNnWvyh p..t tr Pm IlyYrs N.) •i~po~f- u ? ? ? ioo o[ J~ TWE Oi ffwr 11lKU. p~. Yso •~d~. uUU1~Y . a o V- W = ZO/. ~NJUIIY OCCIiRIIEQ mt. tLA~E p? iMJUIIY ~ w~Aort l~iat. mJ. pTt. TpWN, q! ~p~ATqw OpUNTY STATE " wN~ ~T ~ wT wMw.E ~ /~~.lk+ar. r.ra. •9tor uq., ac.) 1MOItK AT t011K ' 21.I~tt~nd~dfMd~q~»d/rom D.Q•~. ,to •ndl~afw~A~~li~~on D~ttA oeeur»d ~t m on th~ d~tw ~t~t~d ~Ow~; ~od to th~ b~at o/ m~ knowbdN. lro+n th~ uuw at~f~d. 321 il~~• j~. ~Q~yTYRE ar• so (Deoru t44) ~~?oo~uss 2t~. osre swMCo ~••p~•~• • H.C. ycller.nid :'i.D. rt. Pierce Fla. 8-~- 6 ~ •ClY~~t~. A~~. ~~T~ j,j~. NAME Oi CEMETENY OR CREYATOR~' 23(. LOCATqM (GY~. (Y~Ot~. M fM1~f/) (S7~ff) RE~WVK (Spen//1. Burial 8-6- 6 PaL~r~, Ce.;:ete Ft. Pierce Fla. :d.:ral Y. 9. /dl Z 2{. NNERAL OUI OII'S SIGNATURE ADORESS 25. DATE RECQ ~Y IOCAI ~EG. 26. 11EGISTMR'S SiGMATURE a•~.1°O6 i•:ilton ~l. Baird 8-10- 6 Anna Lee Denison d.r. - r • ~ tiOf~ OOf1~? 1tl~i lp 1Ytls ~f1d ~~fT+ECt GO~~/ C~ 1f10 ~AO~ Repisfrars record on file in the $f. Luci~ County He~hh Dep~t} n~t ~t ~o~t P~°ro°' Fbrid~' F~LEO ANO RECORDED _ (Warnir?p: Not vaHd unless roised sesl of ths St. Lucl~ gT. LUCIE COUNTY. FLA. _ Counry H~ahhY Department is sffixed) ~ ~ F. ~ , ~ p . . . `701 N. D. MILLER, M. D. ~ ~ ` : . AP ' _ • c~»? H~~rn off~ a ~ w~~~~ R 2 8 ' ~ .:11~: : i _ ' ~ ~~''-r~ ° - ' ~ - - al~ , ttOG~?t r' iS~tAJ~ `1 Depuly Locsl Reqistru C RK CIf2C~IT ~Q~!a~•• ry.: ~'r~n 4' LE , ~ ,(,_s "i.;;. . - ~---r------~-.c'3t:~Jf~t(~t~r.y?-. -,~4~.~--- • ~ ~~-~..~11~. ~ R i=~'i:~'.~'4~,•. ~ox~.~4 ~a~~ ; :s e~ . _ ~ _ _ ~ -