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HomeMy WebLinkAbout1634 ' _ ~;~.~539 ~ . ~ CEr2TIFtCATE OF DEATH 0.~.:~.~ .t ti~.ML R~i.b~uwnr S.+.~. RATt n~~ no. on~oiv c~ ~~wu?~ F L O A T D A ir?f. O~ IRINT IN ~~w~~~~° 11<OIiTRAR'! NO. MlMAMlM INK OKEASEO-?~AMi ~wst •aa~ ~~s~ ~(I OAiE Of DfATN ~~o~t~, a~~ ~ fEE wil00t fOt .st~rcta~s ~ IREi~TE VE::~ ~Ei21.i:Y ~ H ~ 27 1971 RAC! .rn. ¦~ow. urn[u ww«. wGE-wt w~w~ ~ n•~ u«o~~ ~ o.r DATf Oi WM ~rawr. o~r. COUNIII Of OEAiN w ~ •K 7 1909 Saint l.ucie ~ Whi te 62 ~k ~ auc~ . 6602 . to~+. a~ i OEw ~.sw cm .r.,n ~WSMTw? OR Ol?~ER NS - ~r .a~ w ee~r~, o~n s~ru ..w~~ ~ wc«. .~s w .w „ ~ort Pierce Yes ~ort :'ierce ~lemorial }lospital STwTE d W1M ~ M rot r v.~.~.. ~~r~ GT~ZEN 01 MRIAT COU~+iIIV wtRttEC. NEVER MwttlEO. SI~N~? S~OVSE 11~ r1/~. ~M Mr(M ~ry ~ o,,..¦., wwowcu. orvo o~+..c..~ Ke r 1 e ~.,,u.~.«.~. , Wisconsin ~ USA ,~.~larrie Sam D. y ..ru au.uo . ~ul SE47bi11 M1iYE~ Uiu~l OCMwT~p+ iu.n a..~ a.raa ew rw~.~o .ou a [rr0 OF MlSNESS Ot INDUSTRr es r M~w OCCw~fs w rWaM UN. Mw w~~n~e0 ~ T ~ „395-10-5405 u._ I.'ousetvife ~one :~LMrCf M~OY ~ESIOENCE-SfAfE COlMI~II C1T11. TOMM.'O! IOCAi10N wsw cin ~~w~ 1ttEET ANO lWM~E ~ s.ean •ei a .o ,yFlorida ,MSt. Lucie rort Picrce l~o ,w414 Gasparilla Avenue fwtnEt-wwt rw~ .m~ wr ~r+Ot?~ft-wu~DE?+N~wE ~w~ rwu w~ „ William f'srue~GO I,• Alice Dolan f INf~RMANT-NAMf MAIIN(' A~i~fSS 1ftN~t M~.~.~. MO., C11t O~ W~. fT~M, ir1 ~1r. Sam D. Kerley i,,,~1= Gasparilla Ave., Ft. Pierce, F1a.33450 ?wRt p~TM wwS CwuSEO ~r: ~tnrER awr onE ewvsE ~E~ iwE ~d hL A). ~?~D kN w~.i~. o w~ .r ~e.+~. ww wse , I f xti~ G J ~i~ie.r~~%a31. Z h/'.S pl . • ? i ( ~ ~ ,%"lrCl' K' ~ , . . ~ COM~1110M1, ~M, ~.~c: o..e ~n~ w i~1 ; ~~~4N~ft C~YH w. M q. M~f ~ CW+feOMK~ M: i wf0 C YN ui~ t~ ' ' 1~~t ¦ OTtiER SIGNMKwNT COnWt10MS: co~r~wws caaw~+~+c ro a.r.. wi ..ot ¦~u.~s ro c.~u o~nr ru~ M'?ES ~~u ~~..n..o~ ca.- ~n~ .w~ owu~ Mn....wwo c.rs~ a ~u~. . i s iw ~w ~ y..eeY 1 K-~ C~DEN~9~i0E ..o~~w. w~, i HOW INll/~~ OCCUltEO ~~•n~ ...Me p~wwrn iu~ . w rur w, wue u~ ~ W~~~ MOEi , q ~7~pEtEtlrv~[D n1~ ~ ~70. M.'701 ~ INAH~ AT 1NqK ?UCE 01 N/1~r ~~Ow. ~~v. ft~tll, ~K~On. I 10CAilOlV 1 N~~tt O~ ~.7.1. MO.. t~n M t0~+. Nw 1 11N411 ~ff q MO~ OAICt K~G..~K 1YKV11 ~ ]M 7M ~ ~ CEtTYKwi~O~+- .o.nw r~ n.~ .a.n. w. ~ u+o usr a.. .wi.r~ .~w~ ow i as/oe wr wr we o~wrw OCCUMto .i na .u~ce. w w rM~s~uu+: i .a.n. w. n~ wn um ~a.w. ~ ~.n. w, w w wu t0 1 . a.. a~w.+ou. sw ,...,»o.. t p i~ ( J z~ i ~ ~ t~, s z7 7( i~~ c~ .o w,,..,, ,~..,o JI~ aa.su rw. ~ID CHtMKAT1~I-MEOKA~ E~AM~'1Et OA CO~ONEt: Ow TM ~~f~! W iwl row o/ a.w~ r.i ~eawr* .u no.~o~..n~ Mu ~~u~w~nOr p M W~~ w/M Mt wv~ft~WtqM. w r~ O?wW~+. ~ rWQ+fM M~ y~!~! W,+~ N~m ODU~NO d+ M Mq w~M b wy UYSe~L ft~RO. . M i 77~ a7 r 5 ~ 7T~ M Cfii~f~E~-w~wE ~r~ a rwn SrG?~wTWtE. / wene oL~~ne r wTE c O i .•w~ Bernard D. Rosa, M.D. vs~..~.{ . i ~ '!a . ~ ~ ~L_ STYf[ q~ r D w0. ~~~t G Wr~+ ft q [N ~'l~or~~~"f`~ucie Sho ina Center Fort Pierce o da WRW. GEMAT~ON. ~EMO~M fMETfRt Ot CREM~TORY-NnvE IOG~TION an p ~ow~ sr.q Burial ,Nl:illcrest ~:e:-~ori~.1 Fort Pierce, Florida ~ O~TE ~.wrw ~.r, nu~ WNEW MOME-NA1ME AND AL:dEST ; Pu1t O~ ~.r.~. ..o., cq• M ro.r, au~~, tw ~ - . ,y August ~O,I971 ~1'ates FG::era? ::c:ie, ::ox 777 Ft. F'ierce ~~la. 33~7n r. 5. ~612 ~v+eu? - etc,~ -ve+wrun o.n actnto ?ow uasr~.~ ; Rw.191o ,A , ~ A,uqust 3(1 1q71 , ~ ~ I. her~by aertifj? this to b~ • tn~ ~nd aorr~ect oopy af the lccaf M ~ ~ Re~lmara rooord on ftfs in 1h~ St. tuct~ County He~hh DspaA~ ~i1ai~'~" . m~nt at Forf P4ro~, Fbrida. FI~ED ANO RECOR~EO _ ; ST.lUC1F COUMTY fLA- ~ ltOCER POITRAS ~ ~ (WWnirq: Not valid unl~ss ralsed s~a! of the St. L,ud~ ~~~Rx CIRCUI? COURT ~ CouMy H~sith D~partm~nt is affixed.) RECORO VEpIFIEO ~ N. o. ~ o. S~r 13 3 44 PM't t ~ ~ ~ ~ . ~ ' ~ - Count~? H~atth Offiat d~ t+oa) Rplstr~r ~ ' . ' ;s - ~ , e •~/L_ Y ~ ~ ~ - ~".I ~ ~ alr D~IAr IOC~~ R~O~f1?N ~ . ~ . , ' ~ ' ~ . ' , ~ ~~t ' ~ ~~~~i.i~`~' l S _...EL:.C•`~ € ~ 8ooK195 ~1632 ~ . ; . , _ . _ . . } , , . ~ . ~ - t-~~