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HomeMy WebLinkAbout0138 . ~ ~ ; _ , ~ 245848 ~ ~ ~ ~ ~ _ _ ~ ~ : ~ f - - - - _ - - - - - - - - ~ ; st~~e s~~a or Hee~~ CERTI~ICAT]E OF ~EATH S~~ File No. _ ~ ' Purcau of_Vital Statistics . . Registrar's \o. ~ ~ ' ~ ' ~ FLORI'JA ` , I. PI.ACE OF D TH: ~i i USUAL RE:31D1aNCE OF DECEA,ED: ~ ' O ~ ,n~ ~ 1~) Count7 ~y__ D'utriet No. ~ 1 F (a) State Count~i~//• ! {bl Precinet Preeinet No._~~ ~ ( W namc~ not nymber) ` : ,(e) CiVor Cit~or 4' (c) Cit~ or tow ~ • ~ TORO Town N ~ / Y~~ (1 ou•s~de a?7r or w'~j~:} lieiit~. wriu RURAL) - (d) :I~me ot Lospitsl or u~::titutio " ~ U[ nat ia AmD~tal o ~o.titutiou. ~rrit treet numbet or location) (d) Strect Nw _ (e) LcnYtL ot sW: In An 'W or imtitntioa Vr 'j /I[ rural. ~i~ey~ ) : In thiu communiq ' ~ , 1 ee~t7 ~~~r 7t~n. ~ont1~ or dars) lel If foreTrm born. Iwv? bnK in U. A.t 7e~n f . ~ ,J r.,~.~ ~ " 3. FUi.L ~ NAa[E OF DECF 1SED ~ " ~(a) If reter~n. i(b) Social Scenri:r 'i d1CUIC1~ CE::TIFiCAT ON n ~ _ namc.•ar ~ Na ~~"ri+<1 PO_ Date cf Death: ?lcntA ' f_ D2f _ . ~ 4. Se~r 6. Coluorraec 1cs: Y bcwr . lfinut~ ~7i. • ' _ _ f ~ 21. I!e~^,'; c.r:i`~ I a:icnd tF.c dcoe~sr~ [r m ~ ~ 6. Sinrle. m~nied. widmrcd or divorecd ~_^~p.A~jr'a[s 1~ _To _ _Q l9 - ~ G(~) I[ aurried. owed or d' ~ hwban t ~Jor)` ~ . I ` wife ot ~ Ai ~ ji~i?~W~/~S ~i t!.~ i is.t saw h~t_? .ati~c oa 79 i~ ~ er.d tlut dcath oeeuzreJ oa t6c date ~i~d stateJ rbo~e. Dw~tiw ~ o(b) ASe ot b~sband or wi[a. (f ali~~ ~ Y~'rr; ~i I .e cause ot drath ( . 'i 7. Birth date oL deceued ~ •I ~ ~mo ) ldes) { _r~ ' ; - & Ai[e: Yenn 3[oatL~ Dar If le~ tban oae iar ~l Dce . . ~ ~ hrs, r..in. Dce to ~ ~ 'i € ~ 2 IIirtLylace . ; ' ! (Ciyr. ~a or eoudt~) (S~ate or fore::n cona:ry) J~itc+~ c.,nd::ioa. ~ I~..~_ I Inc'.cde L:c«nraeY Kiti~in S n~r.:4~ of urr.t:~i ~ , IO_ lisual ucu. atwn ~ v l1WV~ ~~_i ~ ~ ~ :.:e.~•r i::~.:~sci: : ~ :I. Ir.du~trY_ or Lusinc3 • - oi ot~czncioa; L' '~:4^-::na i ~ _ : ~ ~ tnc c1r.:e to = ~ ~ i2. \~me ~ ~c.~~.h da.t6 ~ r~ ~ 13. Itirth~iaee - - _ (Giceuat~o[o~cracion) }ei~u..iA Lt ~ - oi a~~•~:,,y ~charzrd tla- t M: ~ li~ticsllr. ' • l~. Hn:dea aamc ' ~ ~.c ~ I5. uiretrlaee ;,;,•„ir. s~y due to citera~l uuses. fill in tLe•folloaioQ: i ' 16. Intorman•'s Si:;nature j ~ ~ „ (ul .ieade+.t. su;eide. bomieide (~yxeJr) ` ~ ~:o Addr~ ~b) Latn o: occurrenee ~ ~ ~ ~ (e/ ~tiF.en Ji~l inlury oeeu[T : ~ 17. IIurial, crefr ' w or mmoral7 ! . Cit~ or to~.n) ~CountT) (Sute) s ~ 17 ~k - 1~ P fd) Bi.f ii;urY o:cur in or about ho~ue. on (arm. in iodutitr:rJ Diaec, in i ; 1 ~ ! Y~s::~ vi~«r ~ i& Fuoer~l ~Dircv:tn:'~ Sic ure : ~ ~Spc~iir tiv~ ~t vlaeej ~ ~ IS Add:.u~ ~4biie aL n• ' t (e) {cam o[ injurT . i = ~ _3. Siyraciurr : D. ~ ' i9. Fi3eo ~~t~ ~i 1D v,~ ~ ~ ~ Local i'..y~ictrcr !aJ Addr:s aSe S~Cae1 ~c_s ~ ; ~ _ _ .1' 1 ~ ~ ftQf@~y OOfT1~ 1~11f 10 bQ e trus and oortncf oopy of fho Local - F~ : t .a . ` Registrars record on fIb in tfis St. Luci~ Cou~ry Heahfi Dc,pati- ' . , msnt at foA Piero~. Fiortd~. s,. : (Wuning: Not valid unl~ss rofsed sea! of the St. lucis : ~a~; _ ~ ~ County Fbalth Department is a~xed.) i~' . .;k~: ~j~~~" ~ ~ _ t r , o-< ~~y~ 1 f 1 9 ~ . l ~ ~ ~ : ~ .s` ,1~ ~ k~ N. D. AAILLER, M. D. : ' • . ' . ~ ~f , e.~.~. ~ , COUnfy !th Offio~t dc Locs! istf~r : , • ' ~ ~..,t • i r _ ~~c ~ • ~ - •r-: ~ r- . ~ ~ ; a ~ : : ; ~ : oep~,ry? Locd aecl.t.a? „ _?v :~,;,'~~'c~` • . ~ fIlEO 1?ND RECOROEO • ` ~ ST.IUCIE COUNTY FIA. , ~,J ~1~ ROCER POITRAS ~Q~ "'••rq„.. • ' CIERK Ct :CWt COURT ~V~ - Q R RfCO+~D YERtF1E0~ O8 ~ aoo~ z~0 ~c~ 13$ ~ J~u+ r6 4 0o PN'73 _ - - - - - % ~ _ ~ 2 ~ ~kz y ` ~ t ~ ~ Y ~M~3 ~+w.~ _`.?"',..,'~'„`__'°fr~*._-N}~ _ , , n ~