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HomeMy WebLinkAbout2780 239188 ~ ' , , ~ ~ _ :,.s Da- B7ATE Bo~ao o~ Huux CERTIFICATE OF DEATH coaes • BURiJ1U OF VITAL QTATIS77Ct SiATE FILC NO. ~ea.~ FLORIDA ord ~hen BIRTH NO. AEGISTRAR'S NO. ~ p r o pe r i r' 1. ~U?C~ OI o~AT11 GOD E NO. 2. Uf VAL R[~IOENt[ (~?~en Isrr ti..t U:w.nt~r: R.Nw. M/.~. raecut~d ~~N~ ~ 57ATE s. couwTr •nd •Ill ' Da yl~e~d ~ ~ t. IS REStpENCE . 1 ~ p~~- A. CITY. TOYrN, 04 L..Ca7~0u t. IS ?U1CE Of OEA N t. C1TY. TOWN.OR LOCJITION IItS10E CITY UYITS7 •~n~at 1NStDE UTY 11Y1757 fil~• ~fS MO? L' YES NO . NAM M( i~ ~Myl(~I, /iK Wttf ~IIIdl1 t. STRFET ADDRESS NpS?17A1 OR ~ UtSTITUTION `r 3. nwM[ O/ Fiaat • ViNI~ l~at 4, DATE M«W a1 1'~ ' sceuua °F cnvt.. y.ta~ CICF~O ~:~:'~:'r: ~'.l;d ouTN ~-r . S. SEx i. OOIOR O~t ~e~CE 7. KwRR~ED ~p tiEYER YAItA1E0D ~ NRTN 9 ~6E (/w ~rt~r~ u~oER ~ r ta.oc~ ta Mes. ~ ~.l Iv! O~rQ/~11 Y~.W Dsr. Bwn Mi.. r 1 t• ;Ey~e 1~~(yl~e Nl001rEO? ~pYdtCED e}J ~ y 1~ 1 C11 ~a UwAL OCN~ATION (O~K ~4~ NrNk /OA[ 1~. KIMD Oi WS~P~ESSOR 1NOUSTRY 11. Y1RTN?LACE (JT~tt ~?/N[~?R [N4h1) ~Z• aT~ ~ R~T ~ri .1 eA P~~r- Iuiy ~wt ~JwvYi~/ G~t, ntw i/rthrNl _ . ~.n.oe erator & Fazmer Resort 2~ Far~: i~o h ~ Dl~ek lqk FATNER'S NANE i~. tW7NER'S YAtDEN NAYE ~ or clp~rrlt~r Corne11l1S iriash~'.'i O:1 :3'_'~'&:I ~ZC : _ ts. wss oca~sco fvcR u. a a~rco ~oaccsT ts. socu~ sECUa~Tr ?a. n. ~wro s s~aw?n+e~ ~;lllia.:. J.:sz'~ ari i Sr _ l Yr. r. r..krw1 W rw. ~.w w~~n d rwr~ no 226-0 - 5 wio~,. F:au Pun~~ ~1 1~. CAYft 0/ Y[ATN [J.~wft? ~df ~~s t~wt y[+li~t Je? ia). (D). ss! (t).) IMERYAI tETWEEN . tAl1T L DEATM WAS CAYSEO ~Y~ ~~TM . a, ~.~ee? ,,,,,EO„~~ Unlma:::i cau~e u:.deter.ained .~.s tfl• • an• c•~- clrie.c• Ca.lYio.s.i/aar. p~( To (e) •it? tL• r~icA pa ry~i) . . 1 o e • 1 ~ - ai!Na/ t4 r~4?- r~afstr~f pGE TO (t) . . •1Ch1P 73 J7t+~/ t~1K lut. . O ~AAT {L OTMEII SK~I~ICVR COMpt~OAS COMV~IRwG TO DEATN Oll~ NOT R[tAiED TO iNE 7LIIYINiI 06GSE COMO~~DN WYEN W?Y7 1(1) . WAS AUTOrSY Aout• al- ?ERiWIMEDt c~r d~~t6 ~ ' YES? NO~ or O~for• t ~ID. OfSCRIBC HOW 7lUiiRY OCCURREO. (Ealtl tt~(Y!t ~/n~jur~ i~ POf / M PYf 1/ ~/Iftw ¦~k1sa ~O7 ~ ACCIDENT $UIpOF NOMKIQ . spo~i- ~ ? ? ? Op ~r J T1ME Oi /IIY/ MI~~. a/. Y[O ~ eoa7• ~ i?uu~r w. 0 p. ~ 20/ INJti1111 OCCUNFED 20r. ?UCE OF teuuNr (e. i.. i~ a d+uat ~ose. 7f1f. C1Tr. TOWN. Olt IOCAT1011 OOUNTY STATE MNKE AT ~ IAT YYMICE ~ W~.I~dK1. KrtN. of~SU Gl(1.. tlf.) •1p111( AT MIORK . 1 . to _ 5/1?/6S~~ndl~ata~.~ ti~in ~lir~on D.~.li. ' 2~. / ~tt~nd~d tA~ d~p~~~d lrom _ D~~fA oceurt~d ~t 7• 7. on ih~ d~t~ at~t~d ~Ao~~: ~od to tM b~at ol m~ tno.~ld/~. /rom tA~ uuws st~ud. ~ ?Il lt~~• jj~. tIf.MATYRt ~ (OrpttMt4lt> 71D. ADDRE55 ~~~~0 •r• to D• - • Ber:~ard D. Rass l:.D. Port St. Iucie Shoroin~ Ctr. 5/~/65 •ttYf ~y?tlpM. j]A. pATE I3c. NAME O~ CCMETENY OR CREMATpRr I~. LOCATqA (CYI. fNV~. M t1r~l!) ~ (.g~t) a[rwac Spra/P1 Buria~ -1 -b~ Hillcrest ijem. Garaens Ft. ?ierice, FZa. , V.l.~619 2~. ~"1~NE~l~E OII'S5161'UtTURE ate~~ner• rio~~ ~TERFCO.YYIOCJ~LIIEG. ~i. REG~STRAN'S5~6MATURE . a...1966 Joseph tiJ. Yates :`t.Pierce,Fla. 5-~-b5 Anna :.ee Denison, d.r. ~ - IILEO ~Nt~ REC~AOEO ~i ~ it. tUC1E CCUN Y FLA. ~ IIOCEf~ P01SRA3 i hereby oortify this b be a true and correct oopy of ttys Locy~ CIERK C1=:CUIT COURT - , Registra~a reoord on fllo in the Sf. l,uc;~ Counry F3aa}sh p~pc~t_ REC9~0 YfRtFfEO mant at foA Pinroe, Ftortda. (Warning: Not valtd unless rotsad seat of the St. Lucia wt ~ ~~1 ~H ~7~ < . County Health Depa»ment is effixed,) 239188 q'~ t: 1 , _ ~ N. D. MILLEQ, M. D. ~ ~ ~ ; ti ~ y ) • ; Couny Flealth Off'scer d~ Lxal Stagistr~r ' , , • ~ - ~2. G'P ~c-~ .~Cfc%L J,S',~ . . .a._ _ : • ` , D~if DeptAy EpfS11e? ~ ~ ~ • ~ . ! ~ ~ ~ . ` . ' 1 _i I '1 ~ . 1U~1( ~S PAGE z7~ ~ x..- - - ~ ~ - . . $