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HomeMy WebLinkAbout1512 ~ ~ - - fIIEC AM~ (icOR E' jt. IUCIE COUN~y ~~A• ` 21~r~~ ~10CER IO1TRpt ~ CLERK C~aC~t 00{MT , UECOR~ VERIfI p~.~.... OcT 19 ! ol r!!'11 ` " CERTIFICATE OF DEATH orrwn ~~u Ho ' ' FL08IDA ! t~9IR7H \O. _ REGISTRAR'S NO_~'_Q~ ' PLACE OF ~EATH cone No. 2. USUAL RESIDENCE /RI~~Mew~0ll~d uu¦uwu..:r«s.+.Y.c.r~+. ' a. COUNTY _ a. 57ATE . , COUNTY ~u'~'•~. 3 p . , ~ `•`„•,l.& ~tiLi~4~.~ ~ i~' . ~ - ~ b. CiiY /U a:t~iM ewv~~u :tmiu. rnu L~1:.~L: , c. i~.'.v?M OF ~ C CtTY W~Lld~ owvw~l~ iWV. ~4 IIl'H~LI , ~ OR f STAY + Ot t o ;I 70WN - 7= • TOWH': t ~i nnn~ ~ ~ d. FL':L NAME ~f Ut.~c m+u~~.:.r :uu~::.,c. c.r..::..: a.=.,,s.t :,.ca~..,c d_ STREft ~u nrv. a~« uew~.i ~ i~ HOSP;iAIOR ADDIEZS ~ ~ INSTiTUTION ~ ` ,1 + - - - - - r v. n' ~ ?n [7 - - = - h .n - ; ~ ~c ~i NA~E OF (klnt) c 1~,:.~.::e) 6 ~Iyt) 4. DATE lYontll (Das) (Ywr) DEGEASED OF u . , •.,r.,-..,.~ DEAiM ~tiQV_ ~?~1 Q - i ~ ' fT1.^t or Pr'ntl 1+~ S. SEX COLOA OR RACE NA22~ED. ~:•_3 3.::.:wiPJ, i. CATE OF i![TM j 1. A6E {l~ 7~M ~r ~~~u ~ n~~ a~ oa . 0 . i WiJOL~~J: D:'IOi~':.c~ .~ai•t r , ; Wt ~teuMSi .L~ota~ Dan Hwn ffti i ~ ' -..~'r. _ l v. . ~.7 ~ - i a ~ ~ IOe. U~IiAL OCCU?Ai{ON Oc.• ~~a.i aC ~~r~~ 1Cb. w.N, O~ u~.i:. \SSS 02 IY- ' 71. !(RiHILAC ~itu~ t ht~lp ac~tq) ' IL C~TIZEN OF WHAT .k~u ~+`lzt ar,st ~t ~urua[ L:w „~o ~2 raL+s~ I OJSTIY ~ ` ~ ` COUNT~Y ) N ~ aj _ . . . _ t'' ~ ~ j.i . J .1~ . - - 1 14. lIOiHEtY MAlOEN NA?IE ~ ~ :..'7 i, Il. FATHEi'S tiAl/E ~ i ~ t ~ „~~r ~ a ~ ~ ` _ = - _ ~ 7S. WAS D'cCEASE~ E~ER IN U. S.A0.MEJ FJwCEST t~. SOUA+ SFC:iA::Y ' 17. INC-0IMANTi S16NAiU1lF ' • ~i-i i7~s. ao.•a~.~s~wrol • ~it la d~~ ~~r or uw ot s.rt.:~, . NO. ~ ADDIIESS - - Z ~ r, Y: , ~ • i Y'a------- ; ~.3 , . ~J , ~ I`1E:2'C~• ii. CJIGSE OF DEATH' SIEOICAL GERTIFICATION ~wruv~t •[iWE[N ~ 1 OMKT AMO D[ATN ~..N.i ~ D f:ntrr oaj oo~ u:+e;~• OISEASE OR COtiDt:1CN ~ _ _ i _ ~ v ,cr )'ae lor 1D).' D14ECTlY LEADING 70 DiAiM•~~~ ' ° "t s ~ ~ ~ f~ ~n3 le/ ~ ANTECF~ENT CAUiES F"' ! ~i • L~. TO b' ' _ t'~ - •'Cr~~C.- ~ e I ; Zk:~ ._'~r~ rat s.eaw ~ 1 ~y - r~-~- - i:-~ ~ . 31o.b~d• coRd,:~..-.~. a~ c,... y l~~ p i~ L'n• mo..~ ol ~nwd.~ . s: - , ry~y rrcF, a~ i.ta~i ; a~•rr•. nN to tAs uf...i •..i , i L~: G• W I. Sf:4~ R~3. I~ 11af3R1 llt0 Lltf YFC'.[r.jinJ i.i~.i~' , _ - ~ ~ . " „ ' ~ - ~f S'.,:.._.v:l _ y ~ c.. ~:,.~.c. ..,~r.y. o. h O ,[JAij.b(3:[JI~ wAitA I1. OTMESlSiGN.~:.:-:`17 CG\ . ~ ~ ~ ~ s.:w.d dsath. ~ Cen.i:bora con:- ~ . ! . . ~ or ~ ~ a ~ ~ .~Ls•~.t w t . : . . . ? ~ lfa. DATe OF OPERA•,~fe_ MAJOA P~NJt\.~S Of ~.~~L.~.:1`J , N. AUIOKTI TION ~ _ ~ 5 , ~ res ~ wo ~ .:i - - - - - ~ ,It~..::.i~ +a~~Jn ::6. P:AC.E CF :\1U'Y • ,.r.::~c Yc (C~TlORTOWN IGOYHPf) (STATE) ~~y ZI~. ACCIDENT __..:.:u . ~ u ~a. ws. acs.ia ~7 fu~C:~E ' ~ V NOY:~ t^s _ ~ Ild. :.MC cstx.w~ ~UV~ ~iwr~ ~.i:.r. 2.~. t\J~,tY CCCURr~J 21f. KOW D D INJUt Ut ~~SJ; ~ ~ ~ OF aM:~i , lJ~ hMt:[ t lNJuRY ~ - roc~ ~ .r+~.c Lj ' • F' ~Q u. 1~.~rcL~ cer:i,'~ :ha1 I c:t..r.,.~~ :r c... : ._~r~,_... 13~::, :o~~-. JS,Z. tF.at 1 iarl ra~r tnc u.ccua<•d ` ~ F3 - irom tre tausea a.d ur+ li.~ ~G.f ct .t: ,i chnt c. ~*s .N t, .7~~': (~r,._....~....... _ . _ -r~ -~_Si. - ~i,.,;.,~ ,.r .._c)+ :30. ADDitFSS 23c. DAiE S16NED ~ ~ .j+. SiGl~A7URE , - Lp - - - - - ' l7 $ :i~. 3:i x~ A l. CZE~aA- Nb. DA:E :..~~E~~::Y 03 GAi1.lATOIY .Nd. IOCATiON (C1V. tow4 ~r eounV) IState) C e N T;O!i, AFMOVAI ,e,~c1tJ1 ~ % ~ ~ _ • . • . i . . ' ' _ . - _ • : _ . ~ _ ~ 4 ~ ~ _ ~2 - ry~ ~ _ ~ DATE' t'cC'D tY IOCA~ AEGISTMR'S 5..~ A..< :i. FJKEtAL DI~EGTOI'i Si6NATU0.E ADOI[SS _ wiG. ,3 ~ r _ ~ - ~ ~ 'r• - - ' - r:r~~ - - s:;~ i heraby oertify this 1e bs s trw and oorrcxf ro~y o~ t`?~ Lewl C:egisrrers r~ocord on fib in tfis St. L,uci• Coc:nry Na.~;ih Dcpart- - mant •t Forf Pierw. Ftorida. - - (1Afarning: t~ot va~~d unlsss ratsed seel of the St. l.ucb County Fka~th Departme~t is affixed.) ~ N. D. MILLER, M. D. Coun Health QfficK d~ Loco lstnr / . • - DOput~l LOCA) ReOistra? i ~ 6~ox196 P~i511 ~ ~ ~