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. ! 2Ct11~3 ~~~.,,._,R..=;.a . . ~ Re~tion Dist. No._-.~_ f~: CF.R11F'tCATE O~' DEATH 4 Ile~Lstrars No.-------~~-- VitiJ Statutics - State Bonrd of Hcath c. ) ~ ` G a Birth \o . . ~ ' T~~ r.~ Soutb Carolin. S:.~~~~ F•'r~ ,p ~ 4 WVA`Il~ - U ~A . itA F.\ ~nere Jrtrai.~~~.ea .2 u..tctu2aa: ts+~ao~•t be(o:e ~dmualoo) i' i c ic e n s s~'~r~ S. C. e. a~c.~• 1 C~CC I15 t~ b. ClTY, 7U1~;1, Ug'LC~CATWN ~ c. LEfr'l,`17i OF SfAY c. CIfY. TUK'N. OR I~O(:A77U\ 1N lb ~ r'~iyjC' f ~ YC'~3rS h..'i~1C'\~ > d. \A~1F. UP-- --x {I! oot iu ha~DUa1. sfir~ ~t+ect addres~) ~-ST1tF.EI-~DRESS ~ HO~CITAL OR ~ - IIaS1T1~'1'ION ~ 1 c ~ . . s~te~__~n~~~~ Dacusvil.l e tte ~•~-:c,::~•,~: c• e. LS Y1.ACE OF Uf:ATil ItiS1UE Cf[l' I.1MIrS7 e. IS RFSIDE.\(:E 11~S1DE Cill' f 1~ Bi~Jli)klrZ..`E (k I.L~i1TS7 ? 1i1.~1? ,~O ( YES n r0 ~ YES N O . 1'~a - ~p --;t A-1 F ust d Or ~._:ic~ av tai c ~ ~ D£CF.ASF.D T;t , ~rrrro.v+~~) ~1:~I:~:i D.1V?~ l`:CCLlZLEY ~ nr-..~rje _ ~ c~+c'i I l ~ !00 s f'ir 5. SDC 6. CALUR 7. I~fARR1ED tili~'E.R ~ OK tL1C6 Q ! 8. DATE OF B12i"ilt AGE Qn y~+n ii l'nlrr : 1'i. :i l ud~: •2i Hr~. ~~a + btAliRIEI) ~ + Ioa: b:ntKi~y) ~ ' ~fu I~.y~ `1iow~ ~ M,a. -~3?~--- i t e ~ wtnc~c~~n p nn•oxc~n ~ I 9/ 13 / 1900j C~ I ' ~ 4~ q C.~ lOa. LSVAL t~:l'PATIUI fGi.e k;nd i~f' 106. I:INI) OF BVSINF.SS 11. OIICifiPIaCE (SLte u 1: ~:.'f!~ Z. w~ck dc:.~ ,rt ~C .mvt of r-ockictR Oa,iXDUSTj~Y-`r fo{ciOO cts+n~~f). ~ • Lt f: :T CVV~TRY~ `~....•~~t, p•i~.t~ T .if ~ ' l L~.1. i. ~'j.U~ .t ~ l.'ti ~~r 1. 1 ~ A. ~ ~ t.N A ~ •4 U ~~~~ti^^• :.AD, Ci~: Ciyi1~5 '.';C~.T~ '.i ~ ...~~i L ~ Ct~r~.{i' t ~ _ir , . .`.=Li.f.: ..t `~~=^ti . uci. Lu ' t~1 L . w.~~~r.u uN~ra I . . . , . "_Gti~.~" , ww.~u - ~ ~ (Ta, no, a +wkauwu/ (lf )'cs, Yive~wac o: datrs d~m~ue) ~ ~ . ) ~=`~~i " ?4~-03-4313 :'.1i_cc t, :c ~r,:t~... ~ C. J" ~~$E • ~.~'.'Ai bi ~<,~,Cj'~ 18. GUSE OF DEA77i [F.nter onyr oee uu~e per line for (b). ~nd (c).1 ' 7l1'~"r~ ()\~~'i' t:, ,t7~ YART 2. UF;t:I! «AS CA(?SED HY: ,y~ A`ti 1)F_~171 ~ I}i~tiDIATB CA1358 (~I~.-- - - • - . ~ - ..h <i Con.LU^n~, tf sny, 1 J y:,. 2" shich (11'! n:e to DUE ?n (b)__ ~ L~'~~ Z •:.~ve c.nue ~ - . _ - • ~ 1 O alatinR the ~m:.~r- . i .G~~S~~~ ~ 3~~r~_r,me_ laa. t nLF: T~) (cl-- - - 'A}l: SL Uifil,li ~:c:titi7('tNi CC~\DITiONS CO~I'TRIISUCItiC 70 llEATIf BU'i AOl' flEl_1Ti_I~ TO '1!!E:'iE:R-~:Y. H'~i Ai~ii)t•SY' °iti U[\ ~L ll15EAti.: CO`D~iION GIVEN LY PA1Cf i(~) +•1 tU t,:..~[;:'~? TES KU r ~ E ~ - _ Q ij 7~ F`~ S 20a_ A(:C IJE.rT s~ccrnE Ii0!~fIL'1DE ( 2Ub. UESCRIB ~ib OW II~inIAY OCCUAR~. (k~ter a.tu~c c i u: :u i'_~ f'a.~t Ii ef ~!~m 1K.y ` " f ~ ~ C C r_ <-;; ~ l~t GF-Hcn~r a~:n,it~ u.r. xe., i ~ ~~J~~xv ~ . ~ ~ ~ . y:ir~. Ut~Y O('t'~f f.i:i)-'2ve. I..~C~ OF 1N iJpY ~ ~3~ • ~ n 1 - - - ~l, j (e. r., in ot • .wt 40f. CTtT1f. Uit f ` :4 i".v~: ~ - ~:t ..~'e ~c ti.,t n~ie h~_m~, tarm. (~ct.xr, dre~i. oHke btd~•. ete.l jV'~y yL.. - ~Cwfc at ~~"ort ~ ~~~..~.+l~'./f i ~ : : - - G`C J~ ~ 31. I •ItRid.d the drec~ted f~~m " _y~ ~ , ~ ~ ~-----j y ~ ~ ~ - ~h1 IaN ~av l~:m •t• . _ ,~i:'t'~t. ~S : = ~ ~ ~i i}ra!h i~+n~d at ) : ~ ~ - - m- oe ihn dslc atwt~d •Ixrvr; a~d t.. th. . J a ~ • i r.:. . . . w :.1s. SIGIATGRE - - - - - i t:,~ cr . l ~1 ~ title)/~j~ ~ 22b. t ~`~.SS ~ _ . tiA 1~. r~' G~~ y~ ~ 3 i x i r ~ ~ C ' ~ / i. ~ E ~ -J ' ~ { -~~1 is ~ tt.S~i~ - , 3~, i c Yac. . t ~ ri' ! Vif i c..w. t,~~` ~ f. ~ ( l_v.~' ~1..:.. 4•..:~, i,r ~vutll ~ ~f Crt:~tA71(i.^ ~ 7 ~ . ~ • ~ ' • - - . 5 . . ~ :~s° ;:F~t~~~~.,~_ I.h,/ 16,~ 4,~~c1 Silvcr Groo;: Ccatic.j;~?;cc.-fi\;r..:.._..__:,~,,, ~ '<<!~ 24' }Uti~it.4L I)111EC(UH'J SIC;NATLlR~ Addres~ RS. 1)ATF: HF:Cp. ~ 2fi. ~{~:t:1~Tl11F~'S iiC:~A'I.jf1.F:. ' ;,T..,,, -~....~~,:.'S1 ~:Y, S. CI. L~t tic. ~ L t~l': . i, ~ ~ B~~n ~ ( l..'hiC2 C~ i:~'~'r7~?~~~~ { T ~ ~ ~r~i~ Ir1 ~ . . - t `C l~t'vAi~731F~.T OF IiEA1.7H. F:UUt;ATJUN. AND WELFAH6 - Pubuc llealt4 Setv~w .•.:'.fi."' ' 1 ~ ..-....s.-...+.v~ - • ' . ~ . . . . . . . . . - . . _ . - . ~ . . . FItiED AND RECOROED; : ST. LUCIE COUP~TY. FLA. . „ , . 1 ~r+~ i l~: ~~1 t.. E.~ ~,--~..t~ ~r; _'tl 1C '+~n - . f'.~' ..,..~„'.~'ii ~~:P 2cai~lJ _ r, . ~-•.lr,~_ a, .,r~-.~,1"w?z r tf- t~•_•. y.,' -=~~0 OC1 23 PM !2 : 2 I~ S E P 3 01970 ` • ~ ~ ~ - ~ , • . j` ~ ' ~ • , :.,I~..; . p~7t~-.NS , - I: ~ ` • ~LERK C4RCUtT COURT ' ~ r,'. : . r - ' 4 ' ~ i ' i' + -t ~f' J~.~ l•~% _,:3~,.~i~ ~ a((»r , .a . - C ~ ^ ~ • . • . ~ i aoa~187 ~2586 .v ~ : . _ - - - _