HomeMy WebLinkAbout1357 ~~~e- lTATE BOARD or H~.n+ CERTIFICATE OF DEATH
BUREAU OF VITAL fTATHTIC! iTATE FiL6 NO.
FLORIDA
~•.1 ¦APn.
B~R_H NO REGI6TRAR's NO.
~ ~~~~cea ` PL~ CE OF DEATH cooE No. t. USUAL RESIDENCE ~~ce~e.ae«as.auna tr~+eu~~:..+~a~.e~r4~
r. 1 a. C~:NTY a. STATE b. COUNTY ds~al+l.
Ge pls,l.~
t n per- b. GITY IIt a+t~ld~ to~poraN If~lu. ~t14 AIIH?L) t. L 6TH O G C17Y Qt eWid~ ~M Wlb. ~At~ YISEALI
¦nnent OR STA7lbW~~l~a) Ol
~ r 1 1 P. tOWN T~N
i
i
; d. FULI NAME OF ~tf nt L~lu1 ~r f+ruca~m, tt~ ~tr~et ~dtr•r ~r batl~) d. STtEET It[ nnL s~» Lnt~wi
~ HOStITAI Ot A~~s
~ IN511TUTION ~ O S S _
~ 3. NAME OF a. (Fiat) b. (lliddle) a lLat) DATE lllont?) (DV) (Year)
F DECEASED 0~?TM June 11-1 ;
~r„~ o. m.e, C~lvin C Kelle
~ S. SEX k COLOR OR RACE 7. ?IARRIED, NEVER LUlRR1ED DATE Of tIRTH 1. A6Ep~ v~~N~ ~*m n o~u e~ ~n
WIDOWEO. DIYORCED ~ ~ ' ~r ~ H~ Y~
~ t t ~ • Male White Married Se t 18 6 I
~ s t nl ~ USUAL OCCU?ATIONit1~n t~tl d rrt ~Ob• KINO OF WSINESS OR IN- II. ~IlTH?LACE ~etw ~r twetp swtq~ 12. CITIZEN OF WHAT
• t t n p e r- 6,,. ~ u ntu~Ml DUSTtY COUNTRIf 7
~~^e^~ ~echanic Auto Gara e Cairo Geor ia
n c t 1 nt FATHER'S HAME 11. MOTHEi'S MAI~EN NAYE
~ ~ nP«~ Homer Kelle ~ h
~s. wws ~EC~?sEO~?ERIN U. S.ARMED FORCES) i~. socu~ sECUUnr n. iNioiww~~s s~s~u?ruRepFi.s. ~v~t. elle
/Ta. R r~lno~w) I I It 1~. tin ~~r w 61es ~f ~en7s+1
~ ADGRESS
~ F~~r.N?a1 1~. CAUSE OF DEATH MEDICAL CERTIFICATlON ~n~wv/?L ~ 1
+ 1 r ec to• ::~4r one nm OR CONDITION ownT wN~ otnrn '
~ e r i~ e rer &~e tor la). (b1. DIRfCTIY LEADIN6 TO DEATH'~~~ H e t9 O
~ cnP eer- ne3 (e) #
w,mc~e~?~rcwusa rd Cerabral Accident
~ . i t n t he ~t~ia dors wet s~aw OUE ?O 8 ~
i e c w I t/ e fwode ol d1n+~D. Yorbil n~ditiowR, if sw/. oi~ixo
a~A as Aea.t h•!s?s. siM N tAe a6oss esvar (s1 ~tat- .
- r¢~ s t r a r n~tAswi~. ste. I t suawa i*~ ~~"~D U rem i c C Olil A V~ S
• t t n 1 n T2 ~ di~esM iwjasy, or ~UE TO t
n., u r s ~ f cowylintiaw ~s k i e A OTHER S16NIFtCANT CONDITIONS
: P~ n,~.~ a.a«. c.,~.<<o,~. ~~..~~h~o ~o ~a g er~tQtic Yneumonia Da s f
y ' r Defore ~ +~tel to tAs liuaat or eondition as+uiw issfi.
~ t~ nR an~ Na. DA~E OP O n N Nb. MMOR fINDIN6i OF O?ERATION 10. AUTOKYI ~
~ ~tspost- ~ rci ? No ? ~
;fon of ~
! ~~ob~ai~1 ~~ua) llb. ?LACE OF IHJUlY (as.. u r ~swt tlt (GiY OR TOWN (~UNn? (STATE)
~ y~ ! 2'a. wcc~ocnT ~o~+. hr~, bcc~. Kna. ~~YL. M~) tt rsN, ~ LIISaL-
~ i` Hpluoc
~ 2td. TIME Inaets~ IUar? ~iur~ ~aw~ 31•. INJU~T OCCULtEO Z• OW D 1 U Y UR r p.r
~ ~F •MII~ATD IMT~MiuO dOQ\ lRyf ~5~
i INJURY ~ wo~t ~t~o~i
n1~~.~Q; 19~. ~o~_...~ 1~~ that / last sate ~Ae decea~ed
~ ~1 I hereby cesliJy thot I nttended the deeeaied /ro June 11
. ~ i t e~¦s nlii~e nn J~~ne ond thnt drall~ otcurred ot 11: P m rom lAt cowcs and on l~e dale a~ale~ ~hore.
~ • r~ co De SIGNATURE ~Detne or tfele) ~~~~s tk DATESI6NE0
~ ~ H.~ .~ood~rin Jr M.D. , Ft. Pierce, Fla. June 13-55
~ ~ t4a. • U R I A L, CRE61A- 216_ DATE 24c. NAIAE Of CEMETEIT Ol ClEMATOtr 2W. LOGITION (C"V ~w~, er eo~at~) (Sbt~)
~ ~"~t~~`b"~`'s°"'h' June 14-195~ C Florida ~
~
~ DATE REC'D ~Y IOCAI ~E6ISTRA~'S S16NATURE 1S. FUNE~AL ~ECTO~'S S16NATYRi AD~tEiS _
610 Ave. .
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