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HomeMy WebLinkAbout1053 l1 ~ Y ~ 213~83 . . CERTlFICaTE OF DEATH fTATt FILE NO. - ' FLOAIDA ~BIRTN NO _ . . REGI8TRAR'6 NO_7jQ___ ; PLAGE OF DEATH con~ ~0 2. USUAL RESIDENCE ~w~.e.~.....~u•.d u~.uurw:r..u..r.s.e.. COUNiY a. SiATE C~„TY "~~M~~. . c+ T,,,.t e __^',5-12. F2orida St. Lucie ~ ~ ~ OR ~U `~~L~ W~u. ¦r~a St':uL. c. _Eti_T!i Cr c. C1iY Ut ~.t.w sn.ny uru~='.rW RGfaLI ~ in ~ S'AY,i_-:.:.::>e• Ol - SOWH FOTL P1~2'C8 Z eI~T3 TOWN Ftr• P~@Y~CA - t -x- = r e. FUl? tsAUE OF .u ra w~w.r w«i.w~ a.~• ~j•N :x.:.,.., d. STtEET ~t~ = HOSIIiAL O~ AODtEiS INST~TUTiON Rl K atl ant~ c 1'il'8~. - ---~~A~~~-~OQ' ~ -s ~~.~~E OF . ~t~c..c1 ~L~.?a:~; a ci..c~ i L DATE tYoaul t~.r) tY.a.~ ~ ~ DECEASED ~f /~p~l ZS ZS~Sl ;a, ? I: tiM e~ P~{wt) ~~~1:.~'~' 11d~s ` QfATN i SEX 1. COLOR OR RACE i7. MAtR:ED, NE~fiG 1~!AiR~FD, t. DAT's OF UIiH ~ L A6E;b ~nn •~.w ...H~ ~..n 3 ! W100W"sD.D~.'tOtCEO ~~i...:,; ~ ~~ruus~ .~traf~~ O.n H?.n Yta. ~ - ~ ~ . i 21, 1882 i 6$ + i ; L ) ~ ~ 7 ~ IOa. USUAL OCGU?ATION;G:•. ~:~s at .~rt~ i0~• K~ND OF t13S~7`ESS OR tN- :!1. ~~RTHKACE ~staa .r ~waa~ aw.v~~ , IL CITiZEN Of WMAT " ~ .tw A+.+ut d w~uy liiw .t r~un~l ~ 'J::STRT ~ ~ ~~HtlT1 ~ lerk I U S Postal Servi~e York, Pa. ! •A• u a. ` G j 17. FATHER'S N/WE MOTHER'i MAIOEN NAME - ~ r - c 'Phc~ctas '~1d •"S - _ ' IS. Ww5 DiCEASED ~vit IN i!. S.AWED FORCfi7 ~ 1~. SOCint SiCJt:;Y ' 1). iNFO ANTS SIGNATY~f f~+9~ ~}~e Z• A(~.3~$ . 7 ITM. ea ~r stsw~l I II( 7M. dw ~r ~ htw d wnlnl ~ hOTl@ NO• ~ ADDtESS - ~ Ft_ Pierce~yl{~ w: L ; t~. GAUSE OF DEAM MDDICAL CERTIFICATION wrcwvwi ~rnrcw ;i F.ocer oob on~ umt OISEASE Ot CCND:TION ~i ^ ~ ,~OC~~dial Infarction ~ ~''~`Q~~s ~ i: pe ua~ tor 161. DIlEGTIY LFADIN6 TO OEATFt•~~y ~ _ s ~ ~ p ~ ~nd (e) ~ "o ~ ANiECFDENT G1USF5 ` ~ ~ •7Au dw~ vt weaw D'SE TO (b) r-- C Lu wad~ OJ d%+wY. Yar6i3 cvw3ifioa~, i/ ewl~. ~s-•~r• ~ ^ _ ~ ~ .:N te tM s0ow cstia~ !ai .:at- ncA u Aes?t /a~:art.. ~"Y v g uialew:s. rta It w~a.~~i~y W twd~rt~iwy uns~ tut_ th~ d:~su~. isJ~+li. DL'E TO (:i o ~ ~ eo.~y:.aisww rAi~A~p. pTHER SI6NIFICANT CCNDITCNS .J . ~ ~"Kd Cowd~tioa~ oo~tribaiiwp W :4s fiaLA Dat aot . ~ re~at~3 te t~~ liK.:x or car.._•er_t -e--• n d`a•b M If~. DATE OF OtERA-'If0. MAJOR FiNGtNGi OF O~ERAT:ON ~ ` I0. AUTOKT) 5 , no~ ~ • 1 .~.0 .:oQ ~ ~yY1~.:J~ ~~~'1 ( 21b. ?IAGE OF INJ::flf t, iz oz ._.~t 2~~- ~GTI Ot TOWN (C01lNTY) (STwTE) y ~ ' 21~. weecnexr ' ao~. hre. lacwo. ~:.-•ea..:.:~ a:.1e.. .c ~ i lt nral ~ sL'1uL+ ~ ~LIGtOC ' - 119MI~flC ' Itd. i:utE Wam~ (DV~ t7Crr~ ~l~w~ : 2~~. 1?t3JtY OCCUi~SD ::tf. h W Of INJU T U _ oF i .r:.z.: n .~rr,.._i - ~ IJ~IJli0.T ~ ~ •o~+~ a' ~o~. - " M ~ u I l~creb;/ eerti/y tkat I aLlended tF.r da:ca.ed %ror:. i:_. to 19-• ~nat /:.ut sau 1i.~ ~I:c~nsed .s w alii•e on 15 or.~ ff.at dec:+ _ZSZ:~ ~an.. ~mr+~ !nt ta:tes and un ti,e da:r itc:cd ai•,~: r. - - 3 ~ t]a. $IGNATURE iD~roe or dt:el 130. ADOIIESS ~ 7k_ DwTE S16NED Rirnarri ~ Sfrnott FL. Pierce, Florida 5/3/~ Q ! U R 1 A l, CtEYA-i2~6• OAiE 2sc. t`Ay~ vF Ci'tcTc0.Y Al ClE?1AT0~+ r TW. IOCATION ~C~V. ~~s. or eount~l iStat~) ~ ~ j ~ TION, lE?tOYAL ii~if~) + - r. i ~ ~1•-ia' I~'a-r lst, 1951 : t. D:ierce ..~etery ~ t?t. PierCe~ Florida :OAiE l~FCD ~Y IOCAL~lE61STRA~'S 53GNA:UIE .2S- fUNE~AI GItECTOI'S Sl6NATUlE ADBIEi•. ~ ~ 7-Cil ~.i ~nitg •^:1Cti'7"'~=~.^.~ C:~.^• ~ .iOS@'~~i t~• Ystes. r't.. ~BY'C@~ '~OT'~Qa - i~~ ~ - ~ ; ftbf0~ OOf~I~ 1f11S 10 TI'1M OOfT'eCt OOPy O'F 1~ ~OGa~ • ? Re~imara neoord on fi{s in th~ St. t,uci~ County Heahh Depar~ ~1.3~83 ~ ~ m~snt ~t Fort Piara, Fbrlda. ~ (Wunin~: Not valid unlsss ratsed seat of the St. Luc~ F~LEO aM4 RECOROEO . ~ Counfy Fisslth D~partment is affixed.) St. ROCE CPO taAS,A. CtE~tK C~RGU~T COURt ~ N. D. MILLER, M. D. RECORD VERIFIEQ~..~~.••~ . ~ ~ ~~~uJu~. 30 9 ~a ~N'31' . ~ l~ ~ ' ~ . ~ ~i~ ' ~ ~ ~111y ~IO~.t~ R~OISt?81 ~ ~ ~ Y fi - ~ h::.,.194 1U53 ~ ~ ~ ~ ~ - . _ _ . . . _ _ _