HomeMy WebLinkAbout0134 IGrIGrV I VIGr
Re: The W 1/2 0~ Lot 6, Flarida Coast Line Canal and Transportation Com-
pany Subdivision of the SE 1/4 of Section 34, Township 35 South,
Ranqe 40 East, according to the plat thereof recorded in Plat Book
1, paqe 43, of the public records of St. Lucfe County, Florida,
EXCEPTING THEREFROM the South 25 feet thereof for public roads.
, W:~[trI\G : It is illegal t o,d uplicate this copy b y photostat or photograph.
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T:~is is to cerL~.f~r ~rat tR~~ ~.b~ a true copy of the rec~rd which is on file
in the Pennsylyania Depai~tpdent; dt Health, in accordance rrith Act 66, P. L.
301a approved by, t2~t Gensi~~T,,~ A$s~inbly~ June 29, ~953•
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(ree for this certi.~cat~.e~ $1.00)
Tho~as W. Georges, Jr., M. D. ;
~ ~ ~ ~ Secretary of Health
Harrisburg, Pennsylvania
wvs.to~~a wcv. ~~/ss _ CO~AMONWEAITH Of rENHSYlVAN1A ;
IOC/LL RE(3. NO.__..--~0----------------------------- DE~ARTMENT OF NEAITM i
VITAI STAi15TICS 0 5 619 5-67 '
~~r ~ CERTIFICATE OF DEATH
DIST. NO..~~QO:~-----1(~-
~ ~ 1. DEATH a Cow~ryr b Cily w be~orpM 4. DECEASED'S e. Stn~t addr~, R. D., or b: N~~ber .
occu~uEO Chester Phoenixville ~
u Pikeland Road
i c If dw~ did wo~ oaw iu G1~r b. ?at Offia. Zow~, aed Sto1~ '
~ o? boron0?, ~iw ef 1eM~ip
0
c~ u. a.~ Nr.~..~ Malvern, A.D.#1 Pa. ;
~ d;; H,",p'b, Fhoenixville Hospital Y" p NO ~ '
i
~ w instiHr?ioo ('if wo1 is ho~pilol, yi?~ sM~N oddrenl a. 1AIAid Wor--------•----•--....._._ b. S~riol No--------------•----° !
4 I. NAME OF a(First) b. U~ddM) c(L~st) S. OATE (Month) (Dor) (Y~w) ~
DKEASED
F nrw « w~d • ~~~~}4}- l+. O-T ( - D ~ ~ 2 i
~ 6. WHERE DIO penna `°id d"'°"d °~""'i"P? Charlestown ~
~ ~ECEASED a. StoM----------------~---------•------...__. ? Y~s. d~o~os~d (iwd 'w---------------------•------.._..-----bwn~Mip. ~
~ ACTUALIT Chester ~
IIVET b. Carnhr-----------------•--------...---- ? No, d~o~owd liwd ~ritl~ia actool liwits of--------------._...-•----.._._ a or bwou b. ~
'ty y !
~ 7. SEl( & COIOR OR RACE 9. MARRIED ~ NEVER 1MAItR1ED ? 10. DATE OF SIRTH 11. AGE (ie p~on If und~~ 1 peor If vnder ZI hwrn
~ ?emale I White I w~oowEO p_ oivoRC~ pl4/13/1~$9 ~ b~~~r~ I~„~~„ ~ o~,.l r~,n ( wu~.
, ~ 12. USV~1l OCCUPAjIQN (~w if rNind) ( 19. SOCIAI SECURIiY I'Penna
cE cs~+. w foreqn oow~try)I1S. CITIZEN OF WHAT COUNTRYt
riousewil~e ~
~ ~ 16. f L NAME SE 17. MOTHER'S DEN NAME
~ ~arry~C:~tt ~ Ellen ~lnsley
G , 1& FATHER•s ru~e Tavlor ~~~arrav I~s ~tt~~ nla~vern, R.D.~l ~ Pa.
~ , Herbert L.
~ ; MEDICAL CERTIFICATE c~+••• zo r~.~ zs ..a b. ~.ni«.a br ny~.K~ .~y) INTERVAL 6ETWEEN
' 20. CAUSE OF DEATH: Ew1tr ewhr en~ ca~ pw IiM ix (o), (b) i(~. ONSET AND DEATH
f .
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~ ' MRT 1. DwtM wos cea~d b~n ,
' . IAAAAEDIATE uuse (a) ---~(2~2~o~t-S---~-~---.~:~v~(L...C-----~}.~.t~-~~--------------- ~4?--`~~--~/~dQ~...
-
a ,
~ Conditioas, if w~r, whidi WE TO (b) _
~ ' yaw ris~ fo obow m~
~ (o) sfatiqy tlN ~~d~rlyip -
~ cous~ bst. DUE TO (c)
-
~ IART 11. OTHER SIGNIFICANT CONDITIONS: oo~tn'botiao te d~o1h bvl wo1 nlot~d tu Ne i~diol~ oa~ piwa in ?or1 1(o) 21. WAS AUTOPSY
?ERFORM ?
j ft~t~ii.ii(.CI~J~~t ~tjflr ~`itASL C/~GL SI"GAlkS ~~A7E7~ /Q~(j'i7fQ~(7S Y~ ~No ? ,
22. o. AtCIDENT I~2. b. DESCRIbE MOW ACCIDENT OCCURRED I 42. t TIME Horr MaMh Oap Y~o~ :
S
~ Y~ ~ ~ ~ OF ~
ACCIDEM E.S.T.
22. d. ACCIDENT OCCURREO 22. KACE OF ACCIDENT (~.y., hoN, Z'!. f. CITY, WROl1GH, TOWNSHI? COUNTY STATE
vv~;a w ~+a ~ r~.. .~...~..ka I
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± r.o.k ? 01 r.wk ?
~ 2~• 1 AKtbp a~Mp Nwt 1 oM~wd~d fM abew ww~d d~cwNd awd Mof dw~w eoarrr~d /ro~ tIK owrs~s o~d en tM doh slot~d obor~ Q ES.T.
~ • o. Si not~n L- ~%7. ~ L. ( i ~ 0?O. b. ~I , ~ ~
l t C ` fC J~ o OoN ' e~d G ~
/ s~g
• : 24. o. 6URIAl ~ 21. b. DATE 21. t NAME Cf/YIETERY OR CREMATORY 21. d. LOCAi N(Cifp, doro., Twp., i Covnty) (S~aM)
~ ~o
T~°o~ I 7/2/1967 Morris Cemetery (Phoenixville, Chester, Pa. ~
25. DATE RE~'O ~Y REG. I 46 EGISTRAR'S S URE I SIGNATURE ANO ADDRESS OF FUNERAI OIRECiOR
" ~ .3!' - - u Phoenixville Pa. !
~
~?y ~O
~ 0 AEC RDEp
CE~ PQ1Tq,~=
lA.
~LERK ~ 1
~ RECORO YER~IFIEO Cd~R1 ( ;
~ ~ i
NEILL ORIfFIN JCFiR1E'S L LLOYD ~
"~r~~s instrument CHAR7ENE0 4 zS PM 11
was prepared by P O BO7( 1270. iORT PIERCE, iIORIDA 3D450 - TELEPMONE (305) ~64-A200 ~
~ Chester B. Griffin ,124•A N~, n~}
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