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CERTIFICATE OF DEATH
srrwre Fiu Ho
F L O 8I D A REGISTRAR•s Ho. ~
etRm No. -
1, pLACE OF DEA?H cooc Na b USUAI. RESIDENCE t~r. a.awa u..d u~ru~.wa~ e..~a~. e.ra.
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b. O~ {II wrai0~ e~ea~~+ it~t4~ *rss~ SIIS?L1 e. LEN6iH OF e. CIiY W wusb m~MUb L~tn. ~rw iL'iaL)
~ srwY lr ~u. w~ Ot
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~ d FUII NAME Of W aK L LW1W ~e fYt74t1~ [Ln ~'.rrt ad~+~ ~r ioattad ADDRESS til ta4 s!» Mewr!
HOS?ITAL OR
~ INST{TUTION ~
M ~ 7. NAME OF (FSut) b. (Hidd3~) s(Lst) OFTE (ltoatL) (Ds,s) (Year)
P~.' DECEASED p~TM ~
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W 0 s, Sp( COLOR O~ RI1CE 7. MARRIEG, NEYEA MARRIED, L DATE OF tIRiH f. A6E ~u u~¦~u ~~w a~.•s
WtDOWEO,OIYORCEDIy~eWl 1W~kme~f! 11wW Dq~'8 m~~ttd
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f i0a. USUAL OCCV?ATION~pt» tla/ ~t ~ae~ ~~b. ~NO OF tUSINESt O! IN- 11. QtTH CE ~euu ~r ta~1~a s~trsl I2. CITI2EN OF WHAT
~ ~or d~rta~ ro~t K w~t~[ 1W. wr tt rt1~1 DUSTRY COUNT~Yt
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y~~~ 13. FATHEA'S NAY6 1~. MOTHERY DEN NAYE
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~s. wws ~EC~?seo ert iN u. s.wiweo FoRCESt ik s8ocu?~ sECU~mr i~. INFORMAHTS 516NATIJRE R. L• Byrd
v~ 17N. o~. ~r rtawa) (If sM. stn ~r ~r aw~ K w+sa) U v~Z ~ V ADDRESS
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O~~ 1~. CAUSE OF DEATH MEOICAL CERTIFICATION iKTCavw~ einrcew
Eatee oab on~ nnse a1SE/1SE Ot CONDIiION ONtR AND DGTM
i~~~~D~~ Dit[CTIYlEAD11t6TODEAiH`~~ Art-SClerotic Heart Disease
Hypertrophy with Hypertension
~DE"* M ocardial Failure Scveral Yr
•i11u do~~ +Mt ~wtw 7forbFd oowiitiawb il ~~W. D~+~DDUE TO
~ ~ el.~ awd~ of dt~'~• ~iw to t1u s6svs aaw~ (ol ~wa
" . ~ Nephritis everal Yrs
~ ~ DUE 70 ~ C r . Glom.
' w a;..a.,. :si.~r. «
I '-f_, ~oat~'
~ v 1~~ 7~ 11. OTHER 516NIFICAHT CONDITIONS
I ~ ~ Cowditim~~ c+ostribYtisy to W dtati brt wot
~ ~ • re(ated W tlu diaeaat or toaditiow cas~iw deatk.
r H~. DATE OF O nt
O-N Hb. MAJOR f!llOtN65 OF OPERATION ' 10. AUTOPSY7
~ ~~c3~ res? r+o?
~ ~ ~'1 <I'robasit) l~s) 2ib. fLACE OF INJUIIY <..c.. iawa~uac Ilc. ICIiYO~TOWN (COUNTY) (STATE)
'1 Ili. ACCIDEtR f+rn. t.e~as~. ~r"~.'ae' pat-.'k) I it'+n~ wu fII~aL'f
~ ~ ~ succioe ~
21d. TIME W~rU WvI IT.~) l~1 2~~- ~NJURY OCCURAFD 21 . HOW DID INJUt YR ~
~ W OF fYit[AT 110T1HIlt
O INJURY ~ ¦oac ? atwo~c ? ;
I hereby terti/y that I atf.ended tha deceased /rom~___. 19~, to-~j2.7'' 7. 19~ tAat 1 lase saw lhe deceaacd
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~ ~ alive on l 1 aad tF~at deatA occurred at • ~n rom tlu cavses ond on the date stated abnve.
~ +g z~a. SiGNAT RE lD~re. oz s~w) Iub. w~~ItFSS 73c. DATE SIGNEO
~ R, ^,nnd~rt n,.., Tr~ td ~ ~ Ft. Pierge. Fla. ~--9-~~
-24a, i il R 1 A L, C0.EM/1- 2~b. DATE 2k. NAIAE OF CEMEIEAY OR CRE~tA70tT 2~d. LGCATION (Qt~. W~n, or ~oaat7) tstn/a1-
N +TfON,~~ov~u~s,.ar,o ~ la le Par Miami F1o2'idf3
~ DATE tEC'D tY LOCAI RE615TRAR'S 5:6NA7UiE 2S. FU!lERAI DIRECTOt'S 516NATUJtE ~~~5 V~
~ ~ _ A t Pierce Fla.
FILED ~1NC aECOR0E0
ST.IUCIE COUMTY FIA.
ROCEf °OiTRAS
CLE~[ Li;•~UIT COURT -
RfC~R!' ~':~?If1ED~~
~ 1 hercby rrtify this to be a hw and eorroet-eo~y ef tho Imsl t
Rc~istra~s record on fite In th~ St. Lutb Gour~ty FbatfFt D~tf~~ 3 21o PM ~3
~ trsent at Fot! Pierce. Fiorida. 4 1 3~l~, ~
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~ (Waming: Nat vaiid uniess nised soal at tt?a S!. LtK:o i~~ ~O .~0
eounty Hoafrh uepanmen! fs afftxed,) `ts t•s~y~;
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