HomeMy WebLinkAbout2875 2~65~~ ~
RE: Lots 7, 8 and 9, Block REVISED ~lAP OF FORT PIERCE BEACH
~ according to the plat thereof recorded in Plat Book 8, page
29, public records of St. Lucie County, Florida.
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4 State Board of Health CERTIFIC~~TE aF DF.ATH State F~le No ;
Aegistrar's 1~Io /
~ Bureau oi Vital Statistica F L O R I D A _ ~
1! 1. PLACE OF DfJ~Tfi: ~ 2. USUAL RESIDFI~CS O! DF.CEASED ` ~ • i
/ / ~i ~
1 (a) County • ~~t w~l ~ Dlatrfct tv~ ~ ~ 'i ~a) Sta " Gbti~-f~.~J (L) CountT . ~ _•~-u-'~-'
'3 fb) Prectnci Preclnct Ao ~r l Lt_! - , • , r ; ~ ' •
' ( Wr1te name, not pumber) (c) Ctty or To ~ outside citY•or toq~a U. wriW BUR.~.T-
! /M C~ty or -,r J , C1tY ~ - - ~
' tf Town_ ~!_1; _ yToivnICo•~(~-i~~
,'r( StreetI3o 1C%Z.L^~~~ +l-%: ~ /:=.'-2--` ~
~ ' JO t~in~l.il :C~ 1~.:-''~ L'tYQ
{(d) Name of h~upltal or inst~tutlon`~ ~
(I[ not in hospttal or lnstituUon. write ctreet nur.~Der or iocation) I~ (e) C?~¢n o! Foielan Counti7? 3« na
~ .I (e) Length ot stay: in hospital io;titution :S
At Diaee of death- ~ S C."f ~'`~J It yes. naa~e OOYntr7
lSpeclty whether y ra. months or daysj ~i
? ; ^
? ^ ~ ~l-~t_[.,l~t' ~i
~ ! s. FULL NAD~ OF DDCEAS ~~'~l ~ ~
,I 3 (a) It veteran. ~ 3 (b) Soc1a1 Securi;y ~ ~D~ICA~I. C,~E..A.TIFICATION ^ /
name war .?1~9'~YL-(~ Nio ' t; 20• Data oi Death: on*~
~-~~1Y
- ' V {i yC $m~r 171nu ~t
. . rr: ~ o : TY:.~r%~.
_ H; s, ~ '~-t/ b. Co1or or r~ce_ i' 21. I hereb ttrtity that I nttend the deceaeed fi' `
~ ~ ~ .
_ ~ 6. Single. marrled. wldowed or dieonced.~y~ ~prr T~ ~ ~-L`-'t 1D
h"
1~ 6(~) It ncarriedr~widowed or divorce~. h~sbaad (°r) y ~ that I last aw h W allve or ~ L~- ? aa
d
J''' `i-+ ,G+~-~.v I ~~-~~~!~"C~-L~ that dcath occurred on the date and hour rtated above. Dnzatloa
~ ~ wife oL ~~~e t,
~ h 6(b) Age oi husband or wlte, it tlive 7'2"~ Se~s t• Iminedia~e cause ot dea
- ~ ~ ~ y ; - n .~l~t~/'.a.o-bA~+ ~
_ 7. Btrth date of dece ..L„~ ~.n~--~-~.v ~
(month) (daY) tYear) i~
~E Due to, ~ • •
= o: 8. AYe: Yean ldonths Dqys It lea tl~aa oae daY ~l !i- ? Gi
= s" G g v ~ 3 ~,.li Due
~o
, ^ Y.B1rthP1~~-/f'" ;r~ ..f21r!~ Ol~ercoa itio
: C (City. town ~/rnt~ty) lState or torei countrY) r (Include I~E~4 wlthln S month~ o! deat~
i
! ~ " 10. Usual oecupatl ~
i ` _ ' ~
~ ~ 11. Industry or busin _ ~ta,~or 8ndtngc:
Vnderline
Iru ~ . o~ 7 ot oDUBu Ki~iichdeath
4 t ~ 12. Nem ^ ~
~ ^ w! 13. Blrth tece ~L~ _ i ~ (Glve date ot operatioa) har~cdsti
/7 ti~i ii of autOp5~/ I~4~y
~ _ ° 1 i M i ~ ~ . L--i - Z- ~ - -
~ 14. b1atden name ~ / E1
: " o - . - a-~-C~',_,~_r -
~ i; ~ 75. Birthpla , ~ u. L~c~~ x8,q due to ezternal causes, fill ia the foltoR-ing:
~~h~!%_ .s~ .~-'L// !
~l,
~ ~ 26_ In:ormant's Signatur • (a) (Pzabably) Accldeat, suicide, homicldo (specifrl
y ' ~.~,I r~' L~.P , r ttI (b) Date o! oCCturenCtf
`3 ~ 16 (a1 Addre~ ~ . -
„ . ~ (c) ~Vherc did Wury occ~?
~ ? ~i ~..L i _ _ , (City or town) (Countyy (State)
~ 1;, gurial, cremation or removal
~ ~2 ~ L? <b) Pla~~ ~ r-. t~•'•__ -rl° ~%(d) Di3 inj~Y occur fa or about hoa?e. oa farm. ia lndustrial place.
! 17 (a) Dafe . ' - ~ !n public P~~" -
~.}..a.i.. x._ i, i LfJ - i( (SP~ tYPe oE place)
~ 1& F1u?eral T~lrector's S1gna , , _
C S. 2~0.4 ;r . c,i ~ • ~.J tl While at worY2_,.~..^_{e) Meam ut in7urY-.----
~ ~ l8 (a) Addresa . ~ , ~ ~ / _ t - ' 3i. D.
~ '7 ~L e. ~L..+~ TitG•. IJ i.~.a...C_~ 23. St(;n8 _ `A~ ~
4 t` 19. Filed ' T 1 . Local Rc~trar (a) Address ~ ~-c_v - nate Slgne~~ ~~f 0--
~ a
~ 1 heroby oertify this to b~ e trw end acxrect oopy of fhe tasl
~ Rc~gisrr•rs reoord on fik in th~ St. Luct~ Couny Fieahh D~pert~ ~
;w, mant at Fo+t Piero~. Flortd~. -
M -
~ (Wuning: Not valid untas ntsed seal of the St. Lud~ ~ ~`r
~ County Fiealth Department is affixed.) - - •
• ~ ' ~
, ;
N. D. MILLER, M. D.
Cpun Ith OFfic~r b Loa istrar ~
~ •
• '
`~y Dat~ Deputy toul R~cia.~r . • "
~y
NEILI. ORIFi1N JEF~RIES i LIOrD U R~~U PACf2C7 I~
~»,p-EQE~ BOOK
P O BO% ~270. ~OR~ VIERCE. ~IOFIDA 33450 - 7ELEPMONE ~.305~ •ga-g200 ~
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