HomeMy WebLinkAbout1258 s~- ;~~T~ BOARD o~ Mu~~+ CERTIFICATE OF DEATH
lTATE FIL[ NO.
~a.-s s BUR[/1U OF VITAL fTATIf'T1C!
,.,q.~! rec- • • . ~
.hen FLORIDA
~ ro: erl~ LBIRTN NO. _ RE61sTRAR•6 NO. ~
aecuted 1. PLACE OF DEATH GODH NO. 2. USUAL RESIDENCE ~R3ee~deeewdu~eQ Itwut~tton:re+~deu.~eel~n
tn 1 I 1 COUNTY STATE 6. COUNTY ~°~1ai1.
`,.~e,, St. ~ucie - Florida St Lu
i~ per- b. CITY ur o~c.~a. ~o.von~s u.u.. ~NU acxst? c. lEN6TH OF e. CITY ttt wc.ra. aa.o«.u n.~u. .du Rt%s~L~
aanent OR ~AT~~~~~ jQw}~ i'~t Pierce ~
file. TOWN Ft. Pierce 1 Year .
d. FUII HAAfE OF ~tt mt ~s ewlw x wt~ca~.s, ~~o ac«+.a3~r w Lau~) d SitEET ~u e.r~t s~.~ MntMet
FINStITU 1 NR I+' P H
3. NAME OF a<Pirst) D. qtldaM) e. lI.~t) 4. DAiE (lloatD) (Das) (Yesr)
DECEASED ~TM OC t
~'j f7'rrR o. P.:we) 3 H - _
S, Sp( COIOR OR RACE 7. IAARRIED, NEYER MARLIED DATE OF ~IRTH 1. A6E ~L a u~u ~r .ut~ t~ ~n
~ v W~
WEO, DIYOlCEO lp~etq) ~ ~~i+~sl ri.rY D~n
~ r 1 t e 1•yale W
cialnl~ ~
` e n per- '~a. USUAL OCCU?ATION~OI~a t~.a d.art ~Ob• KIND OF ~USINESS OR IN- 11. {ItTHKACE /saa ~ t.re4. s.rn~ IL CITIZEN OF WHAT
~ me. aY« o...:.~..a~.. ~u...... a.w~.e? DUSTRT A H g USAu NRrtl
, r+nent ~
~ ~ai r
~ i t+c t f nk fATHER'S NAME 1~. MOMERY MAIDEN NAME
~ or
c~;e.rtter U$Qai ab e H
4
IS. WAS DEGEASED ER IN U. S.AR?IED FORCESt 1~. SOCtAI SECU~ITY q. INFOR1dANT5 SI6NATURE J~~~ ~ 9 tg g
lio. ~r ontmn) lu sr. s~n •~r w d~w N~enfn) N
ADDRESS
~„reral I~. CAUSE OF DEATH MEDICAI~ CERTIFICATION ~wTOtvw~ ~mncu~
r e c t or : oter oab one eame ~~SEASE OR CONDITION opsaT wNO oswn~
¦ ~+t f 11 e D~' liae tor (a). 101. DIRECTLY LEADIN6 TO Df/1TH~~~~
cne cer- ~ad (e)
t 1 t i c. c e A~~E~ ~V~
. t t n t d~ •lllu dors wet ~usn DUE TO (b
1 o e O~~ s~o~s ~l /ris0. Yw?i1 eowiiti~w~. iJ sw1.l~+~I
areA u Aeo?! lailue. riar t~ tkt sNM esw (a/ rtat-
+ e~ t s c r a r ~e. /t ~a+u ~*s ~~*1 °"K OUE TO c
. f t h f n 72 li~ew6 ftjsl~,. .
n o u r s • t- to+~yliestiow +o ~ i e• OTHER SICNIFICJIMT CONDITIONS
e er de~tA K~~ death. • C~~~~~y ~,pAM6stiw0 !e /b LstA bs! s~t
o r D e f o r e n/sts~ b As diaea~r o? cowiitiew es~siw ~stA.
~ ek 1 na an~ Hs. DATE Of O?ERA- 11i~. /AA10R FlNDtN6S Of OfFlAi1Qll - ~ 70. AUTOKY~
3lsposl-
t f o n O C •[f ? NO Ll~
~ o~ T. ; irroe.sbl ~so+~h> 21b. tU1CE Of INJURY (ac. ~ K~ 21a (CITY O~ TOWN (COUNIY) (STATE)
~ H 2f~. wee~otHT M4 hef~rs. ~u..t. ~se~~YL. wa) t! nral. wu l[iLL~
fU1CIDt
~ ~ 21d. TIME IN.mU iDVt ~Te..~ ~Na~~ 21~. INJURT OOCUR~ED 2. H W D INJU Y Utt
~ Of ~MUUr wt~~~U
~ INJUtY ~ ~o~~ ? ~Tto~s ?
~ n I henby ceKiJy t hal I at[ended the deuastd /ront 0~ t+ 1 K 1~~, 0~= *_T26 , 19 ~~Aat t bs! sa~o ~/u deuosed
• i c•¦• a[ive nn ~ 19~~nd tha! dPOth a;eurrcd n! ~A ~1+e eawes and on the da~e staeed abore.
ire to De
~ 1]~. SIGNATURE 1D~rw ~r tlW) 21r. ADD~if 2k. OATiS16NE0
-o~plete k
~ e«~••~•. Alva D. Orr M.D. 616 N, th. 3t.Ft.PierceFl 0- -
2~a. ~ U R I A L, CREMA- 216. DATE 24c. NAME Of CEIAETElY OR ClEMATOtY 2~d. IAC.ATION (CiR~. 1ow~, or ~eV) (State) ~
TiON~Ru OYAI ~«us~ r F
OATf RiC'O ~Y LOGAL ItKiSTR~t'S f14NAri~E li. fUMMK q fICNATY~E AOOR~
~.s.~s« ~_2 ~a I,ee Deniaon d.r. Joseph W. Yates, Ft. Pierce, Fls?.
,
. , . -
~ ~
• ' B4RK 187 PA~~` ~.2J0 ,
.~,m.