HomeMy WebLinkAbout0508 .
~ ~ 233184
: ~
:
, .
STATE BOARD oR HPJ?LM CERTIFICATE OF DEATH _
:.ars i BUREAU OF VIT/lL BTAT1o7IGt STATE FILB NO.
~~~,~t r~~_ FLORIDA p
ord •nPn
p~ro;erlr• BI~?H
~a' - REGISTRAR•E NO210
•-creuted 1. Pl.t-CE OF DEATH GODE NO. ' t- USUAL RESIDENCE ~ntinaec~ueat~.~a Icwuat~:n+~eeo.~eet~t~
wnu • t l l ~ a. C0;1Nitt ~ s, STATE b. COUNTY u~/.
De plaetA' ~ ~ 6-1 i~ Flo ida Saint ~ e ;
1n psT' b. CITY Ut ~tirM ceso~rau It~1ty rrtw xwL1 c. IENGiH Of c. CITY (i! wuMt ervw4 1WLL *au~ IIURAL~ ;
..,,.e~ o~ ST YWWsWa) OR Fort Pierce ~
TOWN Fort Pierce Yrs, row?, E
d. FUII N~IME OF (tta~c ~e~1 r iw~~+aw~, s~~~ strac wdrm ~r leeauo~? ~ d, STREET IU ~N. s~w Meu~wf ~
HOSfITAIOR A ~ /1DDRESS =
INSTtTUiION
3. NAME OF (Fint) D. Otiddk) e. (I.ut) OATE (~loatti) (Dy) tYae)
DECEASED OF ~
tTyyr or P.+.U J Pa Lamb o~?n+ No ~y~_
S. SEX GOIOROltACE 7. 1AARIl1fD,HEYERMARRIED, OATE Of iiRTH A6E~i~ ,i~.~~~+~~.,
WIDOWED, DIYOtCED ~~~q~ 4~t ?uudu) ~Y' ta„ Awn YI~.
1~• Male ~ Ne ro Married A r 2 th 18 2
~1A~r IQa. USUAIOCGU1AT10N~Oh~ u.a.r.+~i Ioa. KIND OF tuSINESS OR tN- 11. tt~THttACE ~siu..r u,.~~, s...,e~~ ILGi1ZENOFWw?T
h p~r- IoaJv.~c uc.t...t:.i;a~.~w~t~Ktra~) . DUSfIY C UNTR~~
~ aanent ~~~sr F Wi min ton N.C. IIS~I ~
D2~e1c ink ~y_ ~ATHER'S NwME N, MOTHER'S MAIOEIi NAYE
or -
cyp~¦rlter Ro er Lam ~
tS. WAS OECEASEO~YEIIN U. S.AtMED FO~C~S7 IE. SOCtAL SECURIiY 17. fNFORI./ANTY SlGNATU~! g$r L~b
17n. Wo~+il IIt se. pn ~~r ~e rW d se~.4+1 NO.
ADDRESS
~ unee~l IR CAUSE OF DEATHI MEDICAL CERTIFICATION ~~uv~~ ~rnrccu i
' a?raetor Enter oalr oae eaose DISEASF OR CONDITION pNSCr w~n py~n~
¦ust Cl l• D« tine [or (a). !b). DIRECT~Y IEADIN6 TO OEATN~~~~ O
cne eer- wnd (e/ "
c![leae• ANTECEOENTCAUSES U 10 Da $
~ •?tD tAe ~2Aiadoer+atwsaw DUE TO (p
1 o e w 1 t~• ssdc oJ dyiwp. ~MSi~ eladitisi~, i/ awy, yiviay
arrA u 4east 1a~n• e~ tA~ aian aws ~tat- .
~ e~ t a t r ~r u[Aewis. ~tc. !t werw~ °~D tA~ r*Jt+1~riRD nw !u~-
•fenia 7Z ~A• j;~rue, iwjrry, ~r DUE TO c
no~rs •f- cea~pGs+ti~w +rAieA~~_OTHERSI6NIHCANTCONDITIONS
~cr de~th n~~ +~afF' CMii[iwa awtri~uiwy lo fAs deatk brtt w~t .
or befort r~latrl N lAe disea~e or ~anditiow cawiw dtstA.
•eitns •o) H~. DATE OF O T'O - N6. 1~1MOR FINDIH6S Of OPEltAT10N 70. AlJiO?577
dlspotf-
tlon ef ~ Y[s ? ko ~
i~. U'~w.e1T1 ~trKUS) 210. tLACf OF INJUIIY 1..4. mw.noot 21c (CfTY ORTOWN (COYNiY) (STATE)
~ 21~. ACCIOENT wr. t~~M7. ~tttel. ~cr ?61L. ~tf.) Il RN. ~tW lUi~~.l ~
su~uvc
~ 21d. TIME lu~U IDVI ITnr? IHwrl 2t~, INJURY OGCU0.lED 2l1. HOW DID INJUtY Y~T
, OF 11IMIl[ Ai IIOTlNIL(
(1'J~V~r ~ pO~K ~ 1TtO~R ~
~ zt. I hereby eerliJy that I atlended tha deceaatd /to~n ~Mov_ l 19~, ~o NoV~_,Z9
- IJ~ that I Tast sau tt?e dasased
a> > i as¦• Q?=ve n~.l 19~nd thnt drnti~ oceurrcd at 10 ~ OOPm. rom lht tauses and on tkt da~t s~aled abore.
are to be SIGNATURE (Desrp ot title) lib. AODaESS lk. DATESt6NED
co~yleN ~ ~
, C.C.Benton M.D. Fort Pierce Fla. j 12-1-
2~~. a U R 1 A L, GItEMA• 240. DATE 2<c. ltA?fE OF CE~AEiE~Y OR C~EMATO~Y 2W. LOC~ATION (CiV. towa, or ewnV) (St~u)
~;TION{urS wL I ~ P F P F or da
f~ - _ ~
~CATE AEC'D ~Y IOGAL ~E615TRAll'S SI6NATUtE 2S. FUIiERA1. DItECTO~'S S16NATYlE ADDRESS
~.s.r~oo ~ 12-2-55 Anna Lee :~enison, d.r. dernard R., ~ibson Ft. Pierce F
~
. - {
I hereby certify this fo b~ a true snd correef copy of ths Coul ~
Registrsrs raord on file in the St. l~cie Counry N~a1th Depart- .
ment st FoA Pierce, florida
(Warnirsg: Not valid unless raised seal of the St. itxEe -
' County Heahh Dtpariment affixeda 233184 -
, N. D. MIIIER, M. D. ~ '
Counry Hialtfi-flfficar'~ local Regfatr~K
Ep ANR RE p~~ _
• • 3T. WC~E CO~~it~.~ . . ~
' Il00ER PO~TRAi
~I.' K CIBCIlIT COlMt , ' ' 4 ;
Da D~pury Low! Registrar Q ~ERff1E0,..~..~.~
_ ~IrL 12 ~ 1~ ~'1'!'11
BO~K ~O4 PACE ~
50~
- . .
: ~ ~ , : .
~
. :~...~.,.~==a:~~. ~
~ .W.