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HomeMy WebLinkAbout0469 21,?684 - - f~~EO.Me efcoa~EO ` _ 21~Z684 ~t. ~uci~ ~ouMTr u QOCEF POITIl1f RECORO vER~FiEp COU Ju~ 1Z IO ~ AN'Ti rs» ~TATL ~onwo or NEw~.TM CERTIFICATE OF DEATH • ouauu o~ r~Tw~. srwr~rnco ~rwTC f~ts No. "s•' FLORIDA D~dD~~~7 61RTH NO. REGISTRAR'S NO. iJ ei~eut~d ~UC[ Oi ~[ATN CODE NO. 2- YiWI R[SIO[NC[{w~..~~~r~MwN U.wwtr: R~.~wrM/ry~i.w.w) i apyMn r a. STATE t0~MT1f .°a ."i SL. Lucie ,bb-C~~ Flo;~da St. yucie ; e• ~l.e.~ ; ~ q p~~_ 0. C1TY. TOKM.011 IOC~TiOM a ~~~CE Os cEwiM t. QTY. TOWM.011 lOG?TIOM t• K iES~OtKE a •~s~~t { +M::( C~TY Uu~TS1 uK+OE C~i1l Ur~TSf ~ r.~.. ~ort Pierce ! .cs~ ~oD ~ort Yierce .cs~ w? t L n~Mf Oi (!/wK i~ Wrt~t. /ia ~tr~a d4uQ l[uGTN OF 1 STafET AODI~FSS ~qSMTAI Ow STAt1 tN 15 ~ OM ~ iMMI INST~TUTIOM ? ~ 1~ ::e~. ,_fO$ y„C ~ \j YES? MO ~ 1 1 3 iuurc o~ /lrit A/,t.tt~ Law 1. D~TE Mwt? D~~ Y~a~ 7)DeMpi~f) A1Vll1 S.^.3Yu@ VaI'VE:• DGTM NDii ?i ~,VZ } S. SEx ~ OO1011 d1 ~ACE ~ NARRIE.7 ~~EYER ~tARa~tDC • WTE OF 4117N ! AGE (l~ i~V~ ~~xR t iW v~0[RN WK. !Yt OvIAIt~) N..~b D~w Mwn X.+, j t~• I:ale k'hite w~ooweo ~ o~.op:c~ ~ov. 28 1899 2 y i.f ~1 ~ ~a. usu.~ occu.•ra~ ~c;...~.~ yr..t s... iOD. K~woos a..s,.ress aA u.~:srar 1~ ~~arwuc[ (S~r~ra w/~ray~ cw~rr~l t2 unt[w ~s our oownrr ~ 1 tA y~r- /s.i~I ~wl yw~li~/ h~t. nrw yrdirdi Ti .:xecutive ~.v..iY~~,a..^. ~e~:~sv_va.^.ia V~J~A• pl~et l~k ~ATMEA~S NAYE I~ MOTN(R~S MAtDil1 N11YE •r ( riar Carver ' nliza~e~h riar ton IS. w~S oECUSEO EvE~ w u S. ~~rED fORtES~ u scc:.i scc..w~:r n INfORMAMT ~ SIGNATY~[ J.Tal. Yates, i Tr, r. ~~atrw> /7/ y~. ~.r w. ~ VY• r..ol ~io ?~%7ib-°~~~I -+=s•~•• =t. ~'ierce "r'la. Pun~?~l la. CAYK O/ WTN [~wltt ~slt ~A[ t~wt yt~ G~t /u ,ai. aad ~ri.} IN7[NtiAI ~ETwEEb 31 r~c t~ ~ ~AAT 1. OEATM MAS CAUS[O /r, ~ n~, O~SET AMO DEATM ` ru. ~yrEDUT[ C~YSE __n o_ ~r_~sLaLe ~land cn• e~r- ~ c~ife~c• . i e e e s. C••twiw.. •~s. ~ ouc ro (A) - ! r~K~ ~~K Iw /1 • ~ 1 O G• 1 ~DNt t~t!( R~f t4 ¦w4r. ~ I r~ai~er~r = fsis/•c~~a (ut. D~E TO d ~ ritl~~s 77 E O ?AIIT 11 pf1E11 51G1rt1Wi CGM~pli~p6 CpMiWiMG TO OUiM qJT NpT RI:A7FD 70 Tw( RtY:Mt pY?S[ COUqT~7U GMw M?YT 1(~) W~S AI:TMSY nour• •f- r ?E~iOpyED7 ~ c~r d~~tA s tE5 ? Mo ? or D~f~r• ~ ~ ~~k i s a~ r~ t~ ~ D[S:Ati( rkYO th:,.A1/ pCCu~R[D iEntar R~twe y~w~wry i~ Put ! r P~?t JI y ir~~ t1.) i 7 ~ ACC~DEIIT SU!CIOE MOYKIOE ~ y~~l- W ? L7 ? .w •f v sed~. V 20t TiME Oi /!wr Xw~t~. D~t. Y~o wu~r ~ W A. ~ ~ ZW tM/U~Y OCCYII~EO ?IACE Oi MluNr 1~. in w a'w•;~: ~a~t, 20/ C•" ~Owh.011 LOUt~OM CO~iNTr STATE M~wKE ~T n NQT MMKE ~ JM~+. ~~M?. ~trtd. a3ce af69.. rtr.) ' MIWK AT rp11K ~ 2t. v Gfl. O . . l 2~ 1~02 nd Lst sar •li.~ on a* ~ ~ ~ l~tt~nMdtA~d~.ws~d/rRm + 11J . to _~~='i~ ~ • Air~ --~Tr~ ~ -y~2 ~ D~~fA accurr~d ~f d: L~~ 1~ ~ m on th~ d~b stat~d ~bor~: ~nd to tM D~at o/ mr ino~l~d/~. /rom ~M uuws ~t~(~d ?11 lt~~• jj~ HQIYTYR[ •r• te 1• (~p~trt?ft) Ii: Ai.DRESS I2c. WTESiGMED °o.ol.~. a iiilour S. Turner ~ II22 J:a.^._~e i+venue i.-2~-62 •eerr~t~. 23~ iurY. GRr~Tq~. j~ p~~E j~( MYt JF CEwETEA~ JN CNCMATGAY j3[. ~ATpN ((lf/. bcw. ~r nr~tl/ IST~ft) RfrOYY (tytr~/~l ~ Burial •-2lt-62 ~iillcrest ::e:,. 1ar~er.s ~aint L;:cie :.oLnt .~la. 3.+p12 j! ~U~EMAL [M~IE Oi1 S SIf.NAT4RE App11E55 L~ DATE AtCO. i~ lOG?l REG 26. 11EG~STM11"S SK.MATbRE _ R~~.1i86 Jose~n ri. v3~ES : t.. : i~'?'CG ~d. ~ ::-~C•-C~2 A71;2d 1.e6 .i~ niaon, d:r. ~ 1 her~by aertify tfiis f~ b~ • trw and torr~ect oopy ef tt~e l,ocal - ~ ReQisN.rs reoo~d on fik tn ths St. l~,ci~ Couny l~seahfi Da?aK - ~ msnt ~t Forf Pbra~, flor(da. ` ~ (4Yaming: Not vaJ~d unteu ralsed seal ot the St. L.~Ia ~ - ' ~ County Hsalth Depa~tmsnt is affixed.) - ~ _ , . . ~ N. MILIER. M. D. _ ~ County H~alth Offic~t d~ t.oal Stogi~tr~r f ~ ~ . ; ~~.:~is~G«J ~ ~ . , Dspvty Local Reoistrs? ~ • 4. - ' . - , ~ ~ r• • . ly4 469 . . ~ r. _ ~ . f • - - - : i - - ~ - _ - ~ - - - - - _ -k, ~ ` . _ . . . - . _ . . . ~:~r.~