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HomeMy WebLinkAbout2908 FILED AND RECOR ED ~C Q3E,2 ST.AOGEaPOITRA=~~ ~ 2C Q3f 2 +~~coao v~R FiEO cou~~``c, Oct 30 4s AN'~Q rna. a.- ~rwTC eowaa OR HEA~TH CERTI=;CAT~ OF DEATH , GO~~~ • YURGU OF VITAL YYATIQTiC/ iTAT[ fIL[ NO. t`6'''°`_ FLORIDA ord •A~n A~RTH NO. p~or~r~r REGI6TRAR•S NO. O e[~CUI~d 0I O[ATM coae f~0. I. YSUAL A[~IDCMC[(iaw~/~rNh~1 //w~•Mr: R...L.ry/ryM.~w{w) •ne SL. LLCie !~j~2 • 57ATE rlarida e. couNTr St. L'1C7@ e. o~.o.s !n a~t- A. C~TY. TOMM.OLL LACATIOM t. +S PUCE Or CI11TH t. C~Tr, TOWN.OII IOCATqM a ~S IIES~DEMCE •~d~at " IAS~OE f~TY ttNITS7 UK~OE C~TI UMiTS/ n~.. Ft. Yi~rce ~ES;~ „o? N't. i'ierce ,~5~ ~p I. N~YE Oi (1/ Mt h~yilQ, ~irt K~tN ~.1d~taa) IE~GTN Oi ~ 5T11EET ADOIIESS ~ MOSIIT~~ p11 ON A iAIIMi INST~TuTq11 ; t.Fierce ~~e~:. :ios . ~laY ~r . 20 Ir.d. Hills Drive resQ w? 3. NAM[ OF Fli/If ',V~1Git LIIl pATE ~IMt~ Dh YtY or o«G:~o \ov. ?th. 1960 ; ~~aMp~~r? Ann ::ar~areL Gillis ~TN S. S[X ~ OOIt)11 OII RACE 7. YARiiIED ~p AiYEN 4ANRICD V B. DATE Oi ~IRTN 9 AGE (l~ ~t01 i~~ 1 1~0E~ 2~ WK. t n /MlOV~f?//~~~) M~M D~~ Nwn Mi?. ~ t~~ Female y~~1tQ w~oowco? p1YORCED ~Dr• 17 W p1 Y 1~1a. ::SU~L OCCW~TpM ICik ti~~ y~o~rt pwt IOD, KINOO~ il.S~t~ESSOa u'~puSTNY I1. t~RTNVUCE (Sf~ft w/N~y~ [N~~~) t2. crt~ or rwt cotwntrr •lth y~r- l¦riR~~wty~awtiyl~/r.t~[~IJrpird) a~n~nt Eiousewife Cleveland Ohio USA O~aeY ink t3. fATMER~S JIAMf lt. MpTNEN'S MA1~7EN 11AYE st ~,v••~~~•~ Ja.r.es Carrat barbara ( Lzst aaTe unavaiiable) IS. MIAS OECEASEO EYER tN U. S. ARMEO iO~CE51 16 SGCUI SEC~N~TY wp 17. INfORYAN t{ICIYITYR[ J.~Y . Yate s ~r......~..~...d u~«..«.....~..r.,r...r.~ :~0 A/1~eta 1't. r'ierce Pun~ r~l 1~. CwYK 0/ Y[ATM ~SUtr p!t ~t c~wt prr f.r (s). {D). s+~ (c).1 I~l7ERVA1 DETwEFN dl~~eto~ ~~ATL D[ATNMASCA1iS[O?re . AMDDFATN ¦u~t C11• IMMFOIATE CAYSE Corona t:~i ~::~:Q$Z$ ho~:rs u• e~r- + tltie~t• Ces/itiw,i/~w~, p~ ~p ~ AT`t.EY`l0-S:.1E;:O~i,2C :l@2rt d:sease ~ita ti• r~~t~ ~~a riKi) ! ) 1 e e• 1 ~Dws t~war ( r~ai~tr~r +~~i~I t4~ r~Qr• ~ TO (t? JE:~ ET`2 De2'Lt:"1Si0i1 !ny r~+ur l~st. ~ ' 110Y ~~p ~~1 ~ ?MT 11. OTNq SKwfiCANf C.O~piqr6 CplTIYK(T~aC f0 D4iw R!f p07 REUT[D ro iNE 7Frruui pSFASE Cp~qTpw bryp M fMi 1(~/ . M'~5 AUTOKY p rERfOAME 7 d~atb ~ ~o~-functionin~ Left kianey „ES O No or e.rer• ~ ••~~wt ••1 ~ RCC~DENT wKioc ~pwK~oc ~ ~~R~BE NOW .NJUf1Y pCCuRNED. (Etltr w~fwt ~/~~r~ is Ptlt /M PYf ll ~/ift~ 1/.) ~pe~i- u ? ~ ? ' ~a s•a~. T~~E Oi //a~r XwsU, M/, Y~r v ~wu~r w_ O D• W = 2Q/. 1M1U11Y OCCURRED mr, ?tAtE Oi ~nJUn~ (r. p., in or s'roct Mwe. 7D/. C1TY. TOWN, dl LOCAtqN OpUMTY STATE 1kMIlE AT ~ wpT wNwE ~ IuM. Na0~1. K~etl. oQ:tt 6f10.. tf:.) MIOIIK AT flIO11K 21. I~H~nd~d tM d«,wNd /~om 1y56 . ~a 11~ ~~Ul/ •nd Lst w? Ai~ ~li?~ on 11~ I-~ M~tA occu?t~d ~t B 1~.:. m on th~ d~t~ ~[~t~d ~6or~; ~nd to th~ M~t of m~ lcno~/~d/~. /rom ~h~ uw~s ~taad. ?13 1i~~• ~.s1CNATYR[ co ~uG~ ~ AD°"EU ~/06 ~elaware t1c. o~re sw~co ~a•r~•~• • d.k. Batsche it.~i. r rt Pierce, FIa. 11-16-b0 aee~t~t~. ~~~T~ ~ p~TE 23c. AAMEOFCEMETfRYORCAFMA70AY 23/. LOCATipl1(Cil~.f~fvfl.M[1rA1~) (.9~(t1 ELi•`ia1~S°"~h~ 11-10-60 ~.F-ierce Ce::etery Ft. Pierce Fla.. tl. S. ieiz j~, iUNEML O~ME OII 5 51CNATURE ApDRE55 25. pA7E RECO. ~Y IpCAL pEG. ~EGKTNAR'S SIGMATURE a...~~ee Jose~a N. Ya~es, ?t.Fierce,:ia. 11-17-60 Anna Lee Denison, d.r. I heroby esrtify tfi(t fi bs • true ~nd ootreet capy a` tLa Le~t Rapistr~rs record on file in tfis St. Luds County H~l;h pc,~,:rl• m~nt ~t Fort Pierte, Fbrida. (YVarninp: Not vaNd unleu raised seel of the St. Luc:a , County Heelth Dep~rtment is affixed.) ~"`r . ' ;~•r. . ' ~I t N. D. MILIER, M D. ` • - • , Cax?ry Heatth Gfficer d~ local Ragistrar : ~ " ~ ~ J'. S ~.~~i_.~ . . _ ~.~J ~ljil~i J ~t ""r{~,.,;r ' 1 ~ - t ~ , : ~ `~Y ~OCi) QOgISflal , t~ :t.•'~' I Y r..~~. ~ r: .i ~ ,}f ,e ~ . ~w f;~yi`~ , - ~ ' 0 h ~~i~///IJ~~~I~~t, ~ , a~~18~ ?~~7 . ~ ,~t. . ~ : _ : . _ _