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HomeMy WebLinkAbout1766 _ - 2~3554 ~ ' . CE ~TIFICATE OF DEATH 3TATi FIL[ NO. FLORIDA p1R~H f~0 REGISTRAR_f NO. I'. ~ PLAGE OF DEATN co:;e xo. ~ 2. USUAL RESI~ENCE ~w~aw~.~.....e u..a I( WUI~t1r: MIM~rMf~f~ GO~Ntt a. STATE GOYNTT ~ St. Lucic; = r'InridA _$~._LuCis--- ~ b. CITT ~U wuW ~•t~ u~u?. ..tu YC:uL~ - c, lf:iC,TN OF : a CITY lit wtMb wnw~a W~u. ~rw Wt~W ..r ~ OR ~ STAY ~:t~ a:a:.~ ~ OR , TOWN St. L!2C~t~ Yt'•~Z~~! TOWN St~ jLC~ A Q ~ d. F:1 LL NA?1E OF ~tt ra u. wa~:,~ ~e u~u~:.aa :in iua+z a:..r«a or :.au+.. : d. STtEET ~u ~rrLL ~~w Mc~ttw~~ ~ (J] HJS?:T~ti Oll ADDIESS it`STIT:ITlON C r i ~ y. t T~ i R? i xi ~ ~~si~ic...c~ L:.:~?~~..~~__Dr_. 5~.~...}c~.e~.~.s.~v~~ P+ NAME OF iFinti L ~Yia::r) ~ ILut1 L DATi 4~~W (Dy) (Ywr) DECEASED ' , r.' ~ ~ ~ ~ a ~ i:arry "st._ _ce Seqdal , c~?n~ January 7-195 w !T•rr~ o. P++.U ~ S_ Si]( COIOR Ot RACF O. MA[RIED. \EY~R ?AA4[iED, l. DATE OF ~IITM j L A6E tL ~wry ~~~u , u~~~~~ ~a _ ~ WIOOWEO:DIV00.CiD ~s~.;::r, j ; Wt t+WVI I~~y+ tiw~~~ ~ ~'~:.a : ~~r.i te ~ ~ "~r_~~?d ~_?1-Q2 ~l I , 13~. USJwL OCCUMIIOY,G~n ltd d.ara'+~b. KIND OF 6JS{NESS OR iSi- i 11. ~ItTH~L~CE ~r 1«~«a e.~,~~ 12. CITIZEN OF WNAT ~Q ; artr s,r.y ma~t ~f ~u.'tly LZR ~ti ~ fKUN/ OJSTIT ; ( QQ~t(TtT7 :teal ::s ~a ~v I ~ Kaarney, P:c~braska j u N-- y ll_ FATNFt'S NAME MOTHER'S ?IAIDHi NAME ?•'.Se~del - ---=~=°l~.e 1'°-~~ - ' ti. WAS DECiASEDE~ERIN U. S.ALNFD FOiCSS) lI. SO: tAi SfiGUR1TT 117. lHWRNANTS S16NATY~E J~~;~ ~ ~a~,A9 ' 1T~~. ai. K wi~.il /IL 7K i~~~ K 4L~ ~f Mnln: ' NO. : I .-~G ! ~;_t;_i ' ADDtESS Ft. erc~, a. , ii. GAUSE OP DEATH~ MEDICAL CERTIFICATION `~Kruvwi ~rnrcr,~ j ~~J I '£nter ooy or.~ u-as~ D~SEASE OR CON01TtON owut wwo oe4n~ E Q p.r :ine [or i~). le).~ OIRFGTLT LEADIHG TO OEATH•{~~ ~02''OT1AT'~J ~cclusion ~ ~ ~ ~ aad le) ~ _ ~ ~ MSTEGEDENT CALSFS I •rk:s.:o~~a~i.ara+a~ O::ETO (bl 1 ~ t~.a e.o.i~ o! d?iw~. Y~rLid cowd::~uwa. il a~y. lir:wO ~ -^.r ~a:A ea 4~e•t Jaur+r. to tA~ aG.n~ ra+.u !e~ ~ :cu. ~te_ IC w~~aa~-iw.1 t?~ rw.'.tr:~iwp a:sw :.u~ . 7 i1.1 S:slill. a~.;.ry. D'JE TO - cnw;,:.:c:.o~ r11i~A,11.OTM[RS16:iiFICANTCOND:'i0!:a ~ " ~ rcw~d dtai~, ~ . Cowditi~w cowtnLa:iw;, tu S.'.~ .:..a:~ Sx: ~as .~L:t~J to U~ dfs•a.~ o- o~r..i:•..-r, c_~~,;-..• uat:_ w tfa. DAIE OF OIE0.w-.Nl. MAJOI FINOtN65 DF O?E.'v.7:O~1 m. AYTOKT7 ' : ~ roK ~ p~ ru C Hop:_ ~ ~a::J~ ~lV~c1.s~ 1lb. ?UCE GF :.`i; '7Y a.• 2:c- (GiTYOITOWN (GOUNiY) (STATE) - ~ li~- wcc~ccaT ' s;.c.s t•.=. :.<:-rr....-a. It rur~.. nw AC1aL; ~y s~~c~oc W . -1~~t'_i~E ?1 ~ . 21d. T.trc ~~imt~i 1D~f~ ~l"ur~ .l~s, ..":i::nY GC.~:Jt2ED 2:f.liOW DID lNJUtY UR 7 ~e.tt ~t w ~..e : WJUlT ~ ¦;,:c ~ •r.c-• 1 r.crcb~ cer:i;y ci.n: I nftendr.i tre c.c.:eac~ f::,r.: :ic.C.l~_ 15~ lo Jan.~ , 13~_itlAn! I[wl wv lAe decemed r~ ~ ^ s ~•.d it,:: .tc :-c:.-e : ~;.~~v._. ~rom the cowts and on the dat~ stated ¢bort_ _ g 1:~• 51G(\ATURE ilieyn. ur vt:~) JC. AD~LESS 77e. DATESi6NED p~ ?7:_^ T'i~ :~,•~•GL:Y'_f ~ 'r.• 2~iG1'C~• ~R• 1~7~~~+ ~ N ~ A~, CliMA- ND. .7ATC i+:. ~A?tE GF C"sME:FAT Oi CtEMATOIT ~ Iso. LOCAT(OH (Citt, tov~, oe ~oa~4! lSt~tel , ~ --v'~, fi~MGVw: .s:s~:4~ , _ ~ ~ ~ g: ~ . _ ir: ca .,r~^eLery ; r t. Yierae, 'r'1a. ~ i./~;"c 0.iC', ~T IO~.AL ifis~S:AAI'i S:ovAT~.A~ 2S FUNFRAL OIIECTOtY S16NATU~E ADO~ESS ~yG ~E6. ~i ~~7~`3`a -!?^A ._.C:6 _ ~ c~ ~a~' ~~4f.'L~'_'~ Vfi AQ~ C~t~ ~~B2~QA~ Fia~ ~ t hcrO:ry oortify tfiis ie b~ ~ trw and cort'eCi topy o~f fhe 47wi . -,t ;i,' . Rcg:strsrs reoord on fib in th~ St. 4xi~ County i~3kfi Depae~ FEG+~qDEp -~p';•; . ~ msnt at Fo~t Piero~. Florida. fIL~Q ~y~ NtY ft~- - ~~,~~~`t-, (Vllarning: Not va+~d unless roisod seal of tt~e St. Luc1~ St,1~1C~irG00 T~S ' r~f. RGGE s, 1 ~ Counry Fiea~Th Oepartmenr is au:xed.) Ctf~R C~~u~t t ~•~tEO " . ~ 1~FCnR1 Y: .o ~ ~ N. D. MILLER, M. D. 1~ Z 39 P1'~ ~ ~ Co:x? ~Ith Offic~r d~ I ReSistr~r IMiY - r ~ ~ ' . ~o ~ a~. o~,ry ~,a.i R~~~... ~13SS4 - ' ~ • t ~ . ~ ~ - ~ ~ i'~ ~ ~~i ~ _ - - - . . _ - - - _