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HomeMy WebLinkAbout0551 258529 _~~RTI~~IED COPY WE HEREBY CEATI~ THE C01~~ RiPRODUCEO BELOW TO BE A TRUE AND CORRECT COPY OF THE ORIGIN/1L RECOR~•."~Ot~1 il~.~ IN TN~ eURtAU O~ VITAL 6TATISTICS OF THE dTATE OR FLORIQA. Q~PARTM~'1'~OF HEALTN AN~ RENA6IUTATIVH SERVICES. DIVISION Ol~ HEALTM RT, ~~I~~ •fLORIDA. , . a~ ..t~.w f•' . .i< IHOT VALIO UN • TI~•~AT< OF I{ARIDA. O[?AATMEI~lT -0I H[ALTN AND REHABILITATIVE sERY1C[~. OIVI r)."•.. : ~ - , _f i.~ f~- ~ f~ ~ ~ ~ : CMI[/. ~UR[AY ? VITAL <TATIRIC~ ~ i_ . f ~ ~ - n,`~,,._, _ n„_ y'1'1~, ~ - d.~-~, . , . . a~.. ~ . ~ W , ~w~vl . ` • • • iTAit R[G~eTAAR: DIR[C~OA. DIVI~ION VI :~~•:~~~:f ~2G N[A~7N ~ O[IARMWr 0/ N[ALTN AND . ~'.1!*~`,~.~~~.' . • . l~ i ~ ~ ~t`` A[NA\IIlTAT1Y[ KRVIC[~ r~•rl?:. J ~ j;::r~a.~?:. . . . - - fTAT[ .owao or Nru,ni CERTIFICATE OF DEATH OURE/1U OF YITAL iTA~1lTiCt 9?ATE FILB 0 I I 4 9 0 FLOSIDA ~ ~ - BIRTH NO. pEGISTRAR•S NO. 1 lLAC[ 6i OtATN CODE NO. t. YWAL RttlOillCElw~..~1~c~dt.r1 ll.a~t.ewt.w R«~/mMf~n~iwwir) COUNTY • STATE D. COUNTY Hills:,c -~c u=h 39-062 FIGI'1<:a N 1~ZSCGT'GtlE.'~1 A. CITY, TOWN. 011 LOCATpN t. K PLACE Oi DEATN t. CITr. TOwN.OR tOCATqM IS RES~DENCE INStpE GTY LIMITSI INSIOE CITY LIMIT51 ~~i.RID3 YES ~ ND ? ~.:::D3 YFS ~ NO ? I, NRNE OF j~ yyt~, ~~~a affleN) t IENGTM Oi STRFET A0011F55 MOS?17AL OR STA11 iN ID OM A iAAM1 f Y(ST~TU~1 A St .;cse~~ ~ s jicsr,ztal rs ;122 :,~~r~ska e~venue YES? No~ 3 MAM~ O~ Fbrt Vlfflt Ltst 1. OATE Mw~fl D~/ Y't~? ~ oeeus=o c~ro•«v.t.r~ I~:~~.::":.A= L :•ti~}ii~ A~ a°F~rM ~:arch 2d 19t~1 • S. SEX 6~ WIDq OR tACF 7 MARNIED ~ tiEYER MAARiED ~~BiR7M 9 AGf (!R ~tm1 s~~ r~ UNOEA t~ NK. l~t Oi?ULa/) X..eL D~s. Hwn N:.. ~:ale ~tr~ i ~e .noo,~EO p w.~cEO ~:.urie 24 i 897 b t0o_ USUAL OttUtAT10N i0irc tia/rf pZ ~01! IOD. KIND OF YUSINESS OR iNDUSTRV 11. OIt1TNK~LE (Sh(t M~O/fl/q COLA(1~) 12. ClilffJJl ~ RI{~i ~{A(TRY/ t~ri~~ ~o~t e/ w?ktM 6k. era y rdnd) GDerator - ~ervice *.ation ~'_ar.c~~~',er ~^«ar.d USA 13. fATHER'S NAME 1~. YOTMER'S MA~OEN NAME John Richr_on3 ?_ar-r E linkn k~n IS. MAS OECEllSfO EVEI1 IN U. i ApfFD iWlCES~ 16 SOCIAL SECVR~TY !q. 17. IMfORMANT i{IOIMTYR[ 1 Yr. r. ~r w~ltiwl Ill p. ps ir~ d entd Yes F.'tti i o W~~12 G-C'~-;'415 wav~., %22 a? e. u. ewua or ourn (t~..4..s ea~ yn t~ p c.~. ce~. .R~ t~~.~ IttT[RVAL OEiYYEEM r~aT ouni wns~-~~~- a. arenr_ heart BttgC1! ~T ~ OtATM ~ r~ coatujo... t/e.s. ot~ To c~) - - - - - rfEc~ Q~r to ~Doer cnu~i). at~fis~ t~e ~s~cr- Oti To (e) = 1/is~ nest lest. _ 7 ?ART 11. OfIQ SiGti~4R Cd~fiD16 CbMT~lRJTOK TO OGTN ~{li MOr REUTFO t0 TlU iF~rUML D!5[ASf COMOiTptl GlYEN YI ?Alti t(~/ . WAS AUTOPSY ~ ~EtiFORMEDT S YES ? IIO ~ = 2a- ~ DESCRI~E 11pM IIUURY OCCUNREO (Fado w~rrr y r~hr~ i~ pWe ! a P~r~ lI o/irea IA.) ~ Y ACtIDENT SUKIOE IDYICIOE j J ? ? ? j 3 11k TtYE Oi 1/our A[wt~. Ds7. Yev - INJURY s. ~ D. ~ f 24/. INJUNY OCCIlRBED 1~. R11CE 0~ pUU11Y (t. it~ M ~.`~ouf ~ow~t. ~1J CITY. TQMN. OR LOGTqN COU1171f STATE ~ MNILE AT . IbT Kill.E !~?~.1~~. ana. oDte~ ae4.. a~.i _ ~ MORK ~ AT MORK ~ ~ ~ Z~- J.~andedre.dao....~ar.na, ~r. M-artin, x~siden~ •ndl~ataaw h,~ ~li~son a nd~t r • ~n on th~ d~te st~t~Q ~Aw~; ~nd to ths bast o/ m) kno~Jdjs, from th~ uuwa ~f~ted ~ ~s ( cc a fYl~) ?ID ADORE55 7Is. OATE Si6ttE0 ~ JP No. 1 Court House Tamna Fla. 3/2~~6Z 3a BuRiAL. CREMAtql1. ?3D O~TE AME OF CE?IETERY OR LREMATORY 23d. IOCRTIGN (Ltif/, lo¢R. N tOtcat~) (&fCtt) ~ rtErprAt {3psn//) ^ - 1 1 e Tam a Florida F RAL OIAE ~T1A£ 55 a. DATE RECD. !Y LOUIL REO. I6_ RE6tSTRA11'S SIGMATURE ~lount Co ~~h 28,1961 ~ " ~ ~ ~ ~ ~ ~1~`? li`~r1I~VCo ST. LUCIE COUNTY FIA. ~ ROCER POITRAS CLERK C~AC~)~T COURT ~l~ ~ ' ft ~ • ~ ~ ,Ju~ 10 2 29 PM'73 ~ ~ 258529 ~ ~ 44oK 216 PACE 55~ ~ ~ `~Y ~ ~ ~ t ~ ~ ~r ~ p~a."'~ '`s`:d.;~.r?°_ :.x ~.,rz^~~ . . . . ~ W`~~."''r~