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HomeMy WebLinkAbout2130 251409 ~ ' ~ ~~.°-~"ti TAis D~- YTAT~ .^.OARD Or HFJ~~.TR ~ G:::~TIFIC:ti7E Gi ~?Ji~~~l i'j ~ ~ eoaas • gYRGU OR VITAL Y7ATIQTICY STATE FlLE KO. 1ia•1 ~•o- FLORIDA 1. ord ~b~p BIRTH NO. REGISTRAR•3 NO. Zc:Z ta~eut~n~ 2. YtUAI RLS10ElfK(~?M.~sr.rti..t /J.+Ki,.+.+ R...f.r.M/i•~..:~.:..) proy~rl~ 1. KAtt 0/ o[AT11 CODE td0. ~ •ad vill ~KTM t STATE _ 1• OOIiNTY e. pl~e~d. .7t. Lucie 6b-12 Flor~da St. Lucie ~p p~~~ ~ qTY.TOWN.ORLACAT1pN c, ~5 ?UCE Of ~EATN G GT1f.TOWt40A LACATIOM 1S REStp~tiCE ~ ~ ¦~s~~i ~ 1NS1DE C~TY UNIT51 tMS~DE CITY LIMlTS/ ~ r,~.. r Pie e YES~ ~+oC :~t. rierce ~+cp ; . , f. ~uNE OF U/ Mt iw ~~itd. Iiu ~hed d4a~) LE~Tn Oi f. STREET ADDItESS ~ ON A fMMt . - - '"n'~T1T1ON 2 Ol iioston Ave. 2T~rs~. 2 Ol Boston Ave. YES? NoGg - 3. NAY[ OF fl'r~ Alidlls Lut OATE ~la~4 Dq YtO ' + Alice i~. ~d erl ~T" Se t. _ 0 1y59 _ i • S. scx . 6. Ca,o~ oR wKC w~a~co ~ ncv¢a wuue~co ? s_ wTe os w~n~ 9. ~cc Us rroa s wcx ~ ruuc u~ccx x~ws_ t..e eous.i) xwr n.s. a.... x:,. r i s• F`~ W, yf1pOWED? qYORCED i' 18 1ff78 81 ' p 1~ 1 A 1~ 10~. {ISUAI OCCU?AT~OM (QLt ti~1 ~j eNk fowt 100. KtICD OF WStNESS 01l W045TRY 11. /iRTMM.ACE (57ds M f?/tKa ONtilry) IZ. CtT~iGi OF ~fIMT OGtiMiRTt . . . i c a y r- tut¦~ y wrtra~ dk. er~ ~ttirsn ~~p~p~' Housexife O~,~n no:ne klbior. lnciiana U.S.a. ~ D1~Qk l~k 13. /ATNE11'S M~W[ 1~. YOTIIER"S MAWEII MAME O~ ' ~~p••«~•~ Ha ;q. BoHma Pnoeoe Lucinria :4ock ' tS. r~s occcwsco cvca u~ v- s ~Rrea cwiccs> >6. socu~ sccuam ?a. n. ~Nro s a~auTUac L.B. Fdeerly 1 Pr. r. ~ rwk.~w1 Ul w. w~r wr ~r ~w~ rwW 307-16-2025 waa~.. p 1 5osto A e r t. i'~ erce Pua~r~l 1~. CAYfE OI OtATM (6~t~r sdl ~r cawe ysr li~r Jr (~L u! (c).j . ~ I~TEnYAL lETwFEr~ A1r~eto~ ~AIIT L DEATw E~~ Coronary Thro A1bOS1S °N~~~1one T" .ws ti~• . sD• e~r- tlfie~t• ~ Ce~/i:isu.i/uf. pyE ip (0) ~ ~ ~fN tN rlid ~ue ru~ q ~ . . ~ 1 e e• 1 ~Dose tux (i1. r~6lstr~r at~ti'y Gl~ rR~er- p~,'E TO ; .StDin 72 hiy naar tuf. O ?ART 11. OTf4 SKKi1WR COn10~T10NS CaM1~y{RWC TO 04TM !1R M07 R[tAiEO i0 T1[ TGYYMl ORfASE C~0.~1~ON G1rEJr W~MT 1(~ . WAS A4T0?SY ; AOUf• F ?EI1F01IMED7 t~r d~ath ~ YES ? ~O~ _ j or D~lor• ~py. pEStai~ Npyr Wuttr ottuen¢o. (Esrn s~rwe ~/ia,jti~~ ia P~rt I~r Po[ JI yasw it.) • , ¦~k1nE •`s ~ ~caocrr wx~o¢ ~w~.K~oc - , •posl- u ? ? ? Oa •f TIME OF 1/aaI Ma~fl. D~~• Yt~r Dod~. ~ uuuar ' p p. a. ' 20d. IWU11Y OCCUIIRED 20t_ rLALE OF UUUIlY 4.. ia w 1KU! ?s~t. 20% C~TY. TOMfM.01! L.OCATION ODYIiTY STATE ~ wNr.[ ~T ~ wT rrN~ ~ /w~. Ndorr. at.ru. opicr wa~_. ac.) MJRK AT YYORK ~ ~ 2~- 1~et~nd~d tM d~ewaW lrom . to ~nd !ut a~r tii~ dir~ on • DNtA oceurt~d ~t ~~f'? • m on th~ d~b st~tsd ~Swr~: ~nd fo fh~ b~st o1 m~ imrf~d~~. /tom tM uwea al~tsd. ~ ?I1 lt~~• jj~. fIGMA7YNE ((XV/ttMtillt) 2?D. A6DR[SS ?It. OATE51GwED ar• to b• ~.,pl.~. ~ Russell L. Counts ;i.u. '~~ort Yierce, Fla. 10-1-5y •ler~~t~. 23~. BIJNUt. QPU1T~0~. 230. DATE Llt. M~YE OF CEe~ETENY OR CRErATORY 23/. IOGTfON (Ct~. lae~. ~r cattwlf) (Staft) ~emo~`a~'' IO-1-59 Betihel Cer~etery Logansport, indiar~ Y. S. ~61Z 24. ~E ~~`+~~TU~ ADONESS 25. WTE RECD. ~Y tACAI REG. REGKTpwR'S S~GSWATYRE a•..loa6 :iilton 1~J. naird, 610 Ave.C,Ft.Pierce Fla. 10-~-59 ~i.~na Lee Lenison, d.r. - 1 ~ t si:~ _ • . 'r` ~ . 1 ha+eby oertify thb ro be e trw and aorroc.Y aopy af tfie lnral , 1 t` Rogistrars r+eoord on file in tF~ St. Lucb County H-~..altb DC~~ mer~t at Fort Pier+oe. Florick. . - ~ ~ (Waming: Not valid unloss nised ~el af tha St. Wcl~ ~ ~ . : ' : , . ( Cou~ty Healtfi DeP~rtrr?e~t is efflx+sdJ .r = ~ ~ , . ~ N. D. MILIBt, !Ul Q ~ ' , . _ ~ Gots~ry Hoalth Off6ocr l~ Lo",.:J C:~trar . ~ , . 3 ~ , • . ~ ' L~EO AMD 4tEC a 0 ~ °o~"r ~ AO~Elt POIT~~i~ CLLRK CIRGU~T ~OUAT ~ REGORO VER~f1E8w•~ At~t S 4 t~ PM'Z3 eooK z1z PACEz~~ 251409 - . - ~ ,