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HomeMy WebLinkAbout2780 i ~ ~ ~ - - - - - - - ~ ' ~ - ~-~n~- " - . ^ _ w , r ~ r~~. - nwn ~o ~ N~TM CERTIFICATE ~OF DEATH ~ ' • w~~?u or v~~ ~rwrsnc~ ~rwts ~s l•s•l FLOSIDA •ra .ti•. s~ N . RltiliTR/?R•s xo. pr~~~~l~ i •~~s.t~~ 1. PLACE OR DEATH Coos tw. Z USUAL RESID6NCE (w~w~...w~ u~.wrsw: ~ a~• •ill ~ ~U~ . fTATi ~ 1~ ~1as~~ - ~.r- c1TY iu wau. ..s.ew r.a.. wr. ioLtr a tdiCTM Of a CITY ta ~r. ..s.+. tr.r.~ ..r. taaw •s~~wt OR sTAY(bOMWW OR ~ fil~. TOWN ~N A FUII NAMi W/It w 1~ wM~t ~ Ywwar. dw wn~t ~Y~r ~ Mwt~) ~ STtEET /lt A4 aw IwrW HOS~ITAL Ot INSTITIITION I. NAME OF ~ llted) (NM~M) a(L~t) l DAIt (1Me1) (Dy) (Y~ar) DECEASED ~b O~EAiM f 8I1 • 28-1955 ` R r~is! R SEX 1. OOlOI OR Rl1 . MARIIED. NEYER 11ARRIED. l OJ1?i OF tllTM 1. A6i ~ r ~ nu r~~Na ~n vmoowto, ~~r ed ~~.+ai Ma 28 18 ra ~ ti.~w n.w s~. ~a. r i1~ N~, pS11ALOOCYtAiION~o~w br ~t IM. KIND OF WSINEff OR IN• It. ~IRiMfLACi t~tw ~ r..y~ a~.ibf 1!. CITt2EN OFM?HI?T •ac~ w~~,rrswtdwAWrr....~rwt4d/ OufT~Y C zechoslovi aki a U§~'~`~'t . ~laek i~t q. FATM~'S !lAYt 1~ M01MEi's MAIOHI NAMt ~ •r tn~.rts~r 6b1A ' ~t~ w~s o~wsEO ~N u. s.nwEn roac~s~ K. sou~u sfcuiurr n. uuow~wn s~~ruTwa J.W . a es a.ti..~.w...~ ~us....M...r~e..r.w...ra Na nocR~s erce a. i ?r~~e~l 1~. G1YSi Of Dil?tM MEDIC/1L CERTIRICATION wtsn~w~ ~cr~r~ ' ~tr~~s~r LMr wb w~ ~a~ ~p~N°~TO ~l?if1~~ ~8 infraation ~TM •r~t tll• ~ t~• e~r- ' tltfeat• ~ .ia~ e?• ~f'W~a~wtsww Ywii! erwiielwti tl aqali~IWiTO i 1• e • 1 ~ sw1~,~1 ~s+rv. ~ N W aMN ~N f~/ Msa r~~ist~ar W sw/n`iw~ ww N~e. ~ sd~wi~ ~ /t sMw~ •itrf¦ 7• W iw~t t~frrf. M ~E ~ ~ Ye~r• at- eny~is~liw~ s L f~ w Ii. OTH~I fICNIFICAIIT GONDti10Nf t~r ~~atY Cwittirw~ wwt.i~sttM b W lwtA ~t re I ar Nt~~• nlresl b rfsnw w esiida~ Cerebrovasculari~accident t ' . ¦ati~s a~~ It~. DAiE OF O a N~. YAiOt HNOtNCS Off~tATiON 7b IUtiORTt : ' tiq~H- 1 ~n ? wo ? 5 r- • •t ; ITwN?) uMdM tl k IL/1Ci OF I W Y[Y (at. Y w~MK Ilt (qiY Ot TOMIN {OOYNn) (~TA~) • . ' II~. weuoar r. e~. tkws. w++w. ~w ~YS.. +al II~Y. M~r tVt~L~ . i ' w~c~o= - I l1~. TIMQ pr+n~l W~sl 17~wf t=wr/ 2t~. INJUtY OOCYRtED N , s f ~ OF nna~ aT ~or rrras ` ~ IilJU~ ~ ~~e~ ? at~[ ? - n. I kereb~r esrtily elret I attswdcd tAs deuand /.os . to Jan _ 2B _ t~o~ I Ja~t ao.. tAs deceoscd i i ~ f. .r. e. i• ~ aGve os~J~ILe~ ~ a~d tAat dtctl~ ou~urrcd ne 12~ !Ib oanr~a s~d aa !J`e da[~ stated ~boaae. ~ ' e~~11~t• ? SIGNATURE (DSr~ K tlW) ~ f ~ ......s.. F iruiott M.D. 08 3 6th Ft. Pierce 1-28-55 , ~ ~ H.. s u~ i c~n- ~a. a?~ ]Ic. NAYE OF CfilEiEtY O~ C~EMATORT ra. ~oci?noN tcw. «..va~ ts~w~ ; rro~,~or~n..u,~ J~~ 1 1 Ft. Pierae ~emete Ft. Pierce, Fla. a?~ ~o ~r ~oau ~amws s~cNwTUe~ ~s. w~ a~crors s~cw?ru~ nooe~s ~ ~•"•~f0' _ _ L D son d r. Jose h W. Yates Ft. Pierae, Fla. r ~ . ~ . . ~ 2~43U1 FlIED Akt~ RECOitDED , ~ 5?. LUCIE.COUN~~S~A CtE~ .af~;; CO ~ i ~ ~ ~~'Y ~ffY fhk to b! ~ trw N1d COr1rCt oopy Of th~ lot~l ~rr,.-~ ~E; ~ ; R.o~a..r. ~.~d flw u+ s~. Wa. c,a,~+h? H..t~ o.p.~~ i Qa ~M.'~ 3~;~.~~~y r~~~''-•:; . ~ m.m r~ P~ero.. Fio~d.. SEr ~ 1;~~; ~ ai, o~ yr~'=` ~ (11v,min~: r~lof valid un~.a ..b.d ssa~ of th. sr. wd. = z: . , , ~ County ~Fleakh ~D~ps~tment is affix~d.) ~ = :x~ ' - ~ e`.' ' ;~~~.s ~ • ~ Yi . - ~ N. D. MIIIER, M. D. r' ~ ~ ~ H~alth OFficK 8 toul R rar e"JO' b~~d :L'o~ 'S , . , ~ ~j ~ 3 - '~~jniT~r`~:~~~~~ : ~ / ~ ~A ' ~ " a~ D~~ ~aC.d Rlek1?M ~ _ ~ i ~ ~ ~ ~ ~o~K218 ~~2777 : ~ ~ - - _ _ ~ - ~ z ~ ~ ~ ~''~"~r' ~