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Home My WebLink About5713 ~e- BTATE BOARD or H~?~„+ CERTIFICATE OF DEATH ~ 5- ab ~r a~•s • BUREAU OF VITAL RATIfTIC• 8TATE FILE NO. ;•,~~1 _ FLORIDA REGISTRAR'4 NO. V ~ ~~rd ¦hen BIRTH NO. _ ; r o p e t l 7 ~ GODE NO. 2. YfYAI R[s1O[MC[ ( R~e.~ /sW d hed II ~YhJY1~1~1' Rr1IOp N,~~t ~MY~N~I ~ 1 ?LAtt Oi O[ATN ~cecuttd Q ropMTY - • STATE ~i COUNTY ; F~:«d St. Johns 6-0' 6 r'lorida St Johns A. CITY, TOWN.OR LOCATqN t. ~5 iLACE O~ DEATM t. CtTY. TOWN.OR COCATqN t. ~5 RES~DENCE 1 n p!~- iN5!DE CITY UMITS~ ~ 1MS~OE UTY L{~IT57 i !ilent Jt.~ -ust~ne ~ES NO? ~7~ !1 -u$t~r.e YES~ NO? i I. NAME Of (/~MlIt140ly1f~I,/iKlfttN~Ilrtft~i . STREET AODRESS ' MpSPITAI OR s INSTITUTION r •ar-, e lf:T'PP_'F: ~ 3 MAM[ Of F~~M ~l~6/l~ Last ! OATE MaRI? La/ f~~~ ' oceu?uo °f ~ «aaD~~~~~ John Pierce ~avis OEATH a ril 1~ 1 66 a S SEX 6 CO.OR OR RACE ~ qARN1ED NEVER MARRiED? S OATE Oi ltR7H 9 ~GE t/~ )ea~1 ~~p ~ T~ ~ 1~7 (wf Airty ~~I) M.M4 D~y. N~... ll.. = ¦ ~ t e e ji~16 b~'hite w~oowee~ avoncco ~T?11U2S 1 1 b oL~ ~ F t a 1 n 1] ~p~. USU~L OCCUPATqM ~ Cirr ki~/ of rort do~~ IOD KIhD Oi 6U51NESSOR IN[lUSTRY f 1. lIRTNVLIICE lSldt o~ /o~rNw tsn~trjl 12 C~TiZEh Oi rrNl1! CAUViII~~ - .1tT per- Ivin wwlo/rorku/1~Jt.~rrntJrtfirtll , Re~. ' ' Penns lvania U~r $ ¦snent Ret• US Driver `1T'3Y131t'i ?5'~j"$tieT~1 " ~ Dlat~ Ink 1? MOTNER~S MAIDEN NAME ~ ~ ol 13. FATNERS NAYE - ~ ~TP~~riter k k ~ 16 SOCtAL SECURITY NO 17 tM/ORMA S SIaNATYR~ A~~u~ ~ 02 0 1 U ~;rs.Cutnerine ~avis 6 Sanf'orci ~t. ~t.:+ ustine rla ~ 1! CAYf~ 01 YuTN ~E~ftr ~wf/ eiu cawa ptr li~r J~r 1~3. t~). nn/ tc~ j INTERV~L lETtIfEEN . F ~ ~ ~ 1 ONSEt AND DEATM dt~ect0~ P~pT~ pfATNMASCAUSEO~Y~ ~ L - ~ ¦;.~t f11e IMYEOIATE CAUSE _«i. teI°ZOSCIP+Y'i~t1C i'ie'c:.rt ~LQ Ji.abe~:;.4_ _ . - . _ ~ th< Mellitus --1978 ~ tiflc~te Co~l~lio~u. i/~wl. DUE TO 1.0) . _ . - - - _ - - - - ~ . _ . - ~ 1 C ~ t he rAetA oot ns~ (o ~ I o c w 1 oDar raru (o). reqietrar Nd~n/ Ue anQr- OaE TO (c1-- _ . - . . - l~te/ toux IMf. - ~ ~ •St~ln T2 Z WASAUTOtSY - O PART 11 OiNEII SIGlUfK~M COMpl10M COMTRNlR1Mf. ~O DEATN ~Uf MOT REUTiO TO TN( TFIIYIM11l DISEASE COMOiTq11 GMN iN ~MT 117) ho~ire •f- F PERFONMEO~ .a ~ ~ cer desen rE5? NOQ .:3 cr ~etore ~ ~ IRoE.eb) 2M DESCR~SE HOW ~Ml~i1Y OCCcRRFU (F:n~n ndure o(~~jury is Pa~t !or P~ft !I elUrw~ 7~ 1 •sk1n6 •n) ~ ACGDENT SUIUOC ~MtCIDE dfsposf- r~ ~ ? ? t - - - - * " tlon of u ~ L ~ 20t T~ME oF /loar MontA. lNt. 1't~r y~Cx ~i~at 1 _ bod~. u INJURY w. ~ p. n~. _ W - - Z ZOQ INJURY OCCURNED ZOt il~Cf O~ !NlUll~ ,t. in o~ ohorf Aon~t. N)J C~TY. TOWN. OR COCA1ipM ..C(~,UNTY . STATE MNRE AT ~ MpT WNRf ~ 1a~nc. ladory. ihr~t. cJJfct 6Jd/ . t1. 1 - WORK AT WORK - L d~~th ~ ~ ; ~ . L Z~ !~tt~ndsd ths decs~ssd /rom _ SL~t~ 7 9i2~_ to end 1*s~ ais~ a1i~~ ob' 1~!1 ~~V-- De~th occurred ~t • _ m on the d~te at~ted ~bo~e: and ro the b Srt1 ieno~?/~dN• /t~•fM uu~~f abted . ~ 1 1 f le~s jle i1GNATYR[ r a 1 ~ OATE S~GNEO ~ (I+r/ri~ o~ :l lt. 22L ADORES~CtOY~~I' . 1~I~g . - - •'i` +re to ee ' ' _ -~•p~<« • x She e : St.H ~usti Yorid =1 - f^ +ctu~~tl. ~ (QMf+ ZJp 9Uq1Al. CREYIITION. jjlj D~TE z7c PWM° O~ CEyfTERV OR CRFY~TORY Z}d L~' IQN ((jfr.•fAGw.Nt~1 . t 4 „Fi's R[MOV~I (~\V(fl~/1 i 1 Y~. " l~-16-66 San l,orenzo Lemez~r St i . ~'T` ~',~,~a~2 j~ iIiNENALDIRECTORSS~GNATURE ADGAESS ~ 25 D~TfRFCDl~~OC~IREG .R 1~.RA1i76 . 1~M~ ~ . F~ r~, .,.:,t z ~ ~r~' r'i.uie,^;:1 iiome ti;~- il 1 9 196fi .-~F~e~*? a - ~ . - • . _ _ ~ ~ , r~ ~