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HomeMy WebLinkAbout0304 . ~ CERTIFIC...-:: E OF Dcr.~~ . 2'~90~r _ a~~~M~ .t.~ i~~~~6 .pa K~~,.~i~~.~~.~ F L O R I D A s~wzE F1LE No. 1)I~'lilOlY bF IIFAi.ill ^ 7 ri?E. Ot ?MNi IN ~~~~°Q~~1° REGI6TRAR•S NO. ~[[MAHtNT INI[ OECEASED-NAMf ~ust rjaw ~~si SEX . DATE W OEATH ~•or.t~. o.~, ~i.~i SEE MA?0t00[ fOt pfSTdiQWis ~ - , ~ , , , ~ ~ , .~l 7 ^tr-* . ~ RAtE ~~n. weow. w~KU. wwM, AGE-ust u«nt~ ~ r~.~, u1.se~ e o.~ DATE Of ~IIIM ~~~w. o~~. ~COUti~T Of OfwTe1 nc. ~ vecwr ~ u~rwo.. ~ r~.~s ~ ..o? • wy ! «w~s ~ •w ~ ..C~:! ~ C~.~Y+-~ ~ S! I ~k. i~ ~r~n i ~ i . ~ ~U . : CIiY. TOvYN. OR IOCATION Oi OEATM ..s~e~ un u.u*s MOSitiAt Ot OMEt NSTITUTION-NAME ~u ~.a n. urw~. c.w s.rir .w ..uwu ~ vu~.~ .u o~ .w n 7j n..n-~ - . . -i-: ":y..~~--,~ . , 1i , h STATE Oi ~+tM ~ r wOr w r.f.a.. na.f GiIIEN Of we4AT COUNTt~ wUt4+ED. NEVER MA:bfO. (SUtVfVINCL S~ONSE ~ u~rw. G~+e ..w~r n.+.t i cowm ~ . W100WE0. OIVOtCED ~ srec+~ ~ ; usuu nsWVKe 1 ' . • ' • . ~ Ii . • . ~ ill. ' " . - • r~y~e ace.uo ~C~n ~~R USUN OCCU?wi`Or~ ~an ¦wo w raa oa+t owwc wst a KwC Of WSwESS OQ wOUSttY uvto. ~ a.rw ro~awr. aw. m» u~u~uu ~ occuuta _ ~.u~~~n~a..o~ve iJ~'-+"•l7_' ti`l/ IY. . . Ib ~ " . ` •~SWlM~ NhH[ •u~»b'~. IESWENCE-STATf COIiNiY CITY, 70ViN, Oi IOCATtON wf~M Cm ~rns SitEET At/0 NUM~Et L-~ _ _ I VICMt tlt Ol 1q~ _ • ~ . : ,W ~ . . ~ ^ ia ~ ~u ~ia~ : fATnER-rru~E ~~au ..wou us~ MOTHEt-MUIDFN nwME ~~sr ..~soae us* a - ~ - - ,S T; . . . - ; i;, , INfORMANT-NAME MAI?WG ADGRESS ~u~~t~ o~ ~.?.o. no.. tsn w ro.i~, sr.n. =r~ . 17~ . ~"i n . , n...--. . ~ VI . . , " . _ . _ 7~ . • . tAli 1. ^ pEwM WwS CwUSED tY: 1 (Et~tft OrtiY Orrt UUSE IfR [WE fpf (o~, (a~ wnD (c); - ~en+ee~ o»seT +ro ~+•r~ 1~ rreW9 s~ ~a~ <t _c~~~, /~l-~ , • . .xa ~ ~ . % ~o»o,t,o.,. ~ h~ ~ l~?l4 I 7 .+.~cw o,.e ..a w 10I ' i...io~.~t c•uii ~w. we ~o. o~ •s • e seGw..a a: 1~~~~MG twl YMOU- , ~f~MG C~Y1! 111~t I S (C~ 1 fAtT Y. OTMEQ K i CON0ITIONS e~.:w~x.s to.nn~u*uw ro .i» ~Y, woi nuno + t uy e: .~t~ w~ J ~wurorsr li ~FS ve~e i~wo~was eo~' ~l/S ' . Lil~LO :M OlikIWN~NG ULS! G't1~~- Z~~'~~'_~,w/ ' ll ~ l tdct' : l~ ",c~ f,~ c, C~~ o~.,. (a,~bopi~l ACC' "N . ~E Ot~O ~,~pfi~! ~ rOwtw. . ~t~~ ~ MOWt ~ HOW INJURr OCCURIED ~ lwtt~ .r~utl iwiv~~ ~w r.~r ~ W ?~~t .t[r ~ nGatK~Df; O[ 1MOEifW~l.fD ~ " ~ r1r1 2{? 7'Jc M. MI INIURY AT 1MOR~C ?~wCE Of w1Wtr w..e. r•~., s.r~. ~,c*o~. ~ tOCwttO+v ~ l~efft O~ ~.I.~. rq.. 4A W tOrM, S~~R ~ ~ u~nn ns a~.o ~ p/K! NOG., ~K. ~ YK~n ~ ]D~ 7d ~ ~Y CERTIf1UT~ON- ..o.~tw ewr rt..a ~ ..a.m w~ ~u~ uW 4~t LM wt/w1~ NM ON ~ n ~)ry.i M DEnM OCCut7E0 i rwt ?.Kt, v. '.e •M13KIwn: ~ ra+tw wr rtu ~ +~4 M .~wp.ni re. ua. ro*~e te:• 0 ~~m..mo uu i~ . ti/~; _ 7 aw..~oct, o_i ~i~ ceee.uo rw. ~=27=71 ~~ti 2.0-~.8-7 3 ~tt. 1~-18-7 3 . t~~ ~ r l~t. ~G» M o~.e e.:~x.s~ st.•r:. CE~TIf1UT1pN-MEDKw~ Ex~unwfR OR CORONER o.. r~E a.s.s a r.e ..o~~ o• pt.m ~~•e aec~a..r v~•rq~.w..c~o .o ~~rw...a+ w ne ~00~ wo/o~ rwf wvnr~.np.., rr. o~wqw. ~ 1 rd+tw ~ w~ .1.~ wov~ ; 1 ~ y Ot~M p(CY~ttO Ow W Mn ~+O YY! 00 ~M 4VSt111 Si~T1D. . . 72~ M. j t1~ ~ .x CEfii~i~ER-wu~aF mn o~ ?¦wn ~ SiGdwT ~ oeuee o. •n.e • ~~ZE S~G/r.fO, ~~:.~.T.., o.•,•t.~~ r~._ t~~~ M _l vin L4olkoc,rsk ~n? ~ ~ ll ~`T~~ 'n._LLc~1 Nu?+IWG ~DORESS-CfRiu R s~un o. ~.r.o. . c~n ca r r.. ' 802 Nort~ 7th Street ort Pierce, F~orida ~450 N1RfAl, ULEMA110N, Rf/MOVAi CEINETERY Ol CRiMAtQ4Y-N,th1~ ?OCATION o~ W.i.. s+•~t ~ YlCM ~ . Ib. • •Y'_ 7~?. _ 1~c ',i(','_ - . . ~ OATE ~4ra.n., o~~, n.~~ FUNERAt MOIaE-w~Mf wND ~DLaFSS 1 STIfE~~01 fJ.O. w0.~ tm O~ ~0~.., a~.tt, i~?~ 2N ~~T• 1 ~ 1 ~?r7 ~ 7Se _ ' ~l=-:~ -1.~ ; . . V. 5, f612 F~Au iECTOt- tu j_ iEGiSTRwR-S~Gh~iU~F • OwTE tECf~vEO lOCwt tEGUi+wi ' eer.19T0 i'i `~i/~j,i /i~~•_ 2„ i . , . % :I• ~C'. :u .^.V. ~ fIIED AMD ~EC4a0E0 1 hc~y eoftify thia to be a true end corrcct ST. LUCIE +'.OUNTY F~~• cupY v: the l.cytal R~;~. ?~ItRAS ~ Registrars reoord on file !n ths St. Lucie County Hoal~h Dc~~art CIEAI~ C=•~U?i' COURt ~ ~ ~ ment et Fo~t Pierce. F~Of1d0. QF~~;.~ ~[:~tC4E~.....w~ ~ uVi'...... . (Warning: Not valid unlecs raised seal of the St. lucio ~ .~~``'t' `~3r~: s~' Cotinty Heairh Department is affixed.) NQ~ 9 os AM z3 'd~ ~G . _ 'r,. J . t' . : s~ . r ' N. D. MIIIER, M. D. r~ _ . • . _ ~ Count Heaith Officer 3 locol R ~b~~v ~ ^ ' ~ ' . Y egistrar he . d • ~ J ~ ~ ~ ~ " ~ 'y1~0! =i~rr~' ~ti' - -'o~ t~oca~ ~Rea J//? 1 u?'~~'~ ~ . . ; - ~~Rx2Z1 304 - -