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State Board of Health CERTIFICATE OF DEATH State File No
~ Bureau of Vital Statistip F L O RI D A Registraz's No
A
1. PLA,CS OF eDSJ?TH~•~ ~ ~ , 2. USUAL RESIDS\TCE W' DF~
(a) Counq .~.f ~ . ~,Li(.(iC~C.~ Dlstrlct N~ (a) State 1 ~ I
-92.t
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r~~Q/ (bl Co+=tT + ~ s'~ ~
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~ Ib) Precfnct Preclnct No . .
` ( Wr te aame, aot uumber) (c) C1b or To
„(c) C~ty or~~ - Cfty or (Ii outcide citY or War~ t~. WTlte L
~~~.L.c~.~ Town No 6 6 - / 3 3 i ~ ~ . ~ 7
J Town / ~a (d) Stmt Ns-_„ ~
~(d) .7ame ot hospital or SnsUtutloa~~ ~1 ~ 7 " S'-~ ~
(It not in hospltal or fnstttutloo, write strcet numbcr or locatlon) Ly~n p! p'prp,S~f Coua~ n'~ .
~ (el I.enSth ot styr: In Aosptt~l ot lnstltuUO?t Td O! ao
' It Yes. natne rountr7
~+~7 At Diace Ot dea
(Spcetf~ whe years. moatl~s or days)
~ ~ -
~ 3. F[JLL NAIdE OF D*'~'~~~ ~'Q~-""'~"' ~
3(a) It veteraa. s(b) Socfal Securf:7 ICaI. CEItTIFiCATIO~S
:7 . . '
: ~ ~ ..a. ~H Hp ' 30. Date of Death: ~Wnt~ `1- ~ m~ oZ
a ~ ~ / Yeit / 9 Y ~ - gti~r ,f~nuTC Y..
~G 4. S!~_,! y~ 1~ 6. Color o~' w"'~ . 21. I herebY «rti4'lbat I attended the dceeacod fro~'
~ M~' A. Single. marrled. widowred or dlvorceb,s.~ • 3p 1° :
8(~) It nwr~ied. ~vLdowed or dlvorced. hasband oi (~nc) that I Iatt aW altve ia • ar.d
w~ alfe ~ - f ~r that death ocCUrccd on tbe dato aad lw~ ctated abova Dnzatiaat
a°;' ~ 6(b) AYe o! husband or wife. ft st~•••~ ycazs ` te c uso dea
' f,~, 7. siru? a.ce or aeee ~ ! o' 6 L a ~ i~ :
~ ~ ~ mon ) (daY) (Ycar) ~ ~ (,~(.l.I~IJ
~ i. AYe: Yean ~[ont~ D~s I! less than one dV y Due W .
~ ~ N
h ~ ga ii ~ ~
o
-
c 9. BirthNaee ~'^.~C~
-J , Other cas~dltl
I, Q:~ ~ (Cit~. town or oountY) •(State or !or oountry (InClude Dre~aancY wlthfn 3 months of deatt~ I
! ~ ~ 10. Usual oCCUya -
c
i ~ il. Industry or busin ~ Slaior 8ndings:
~ ~ ~ / i o! opern tae
cauj
e~to
! • M 1=. ~Tam ^ w~iehGeaiu
~ W 73. Bitth lar'e ~ (Give dato O! opcrit30n) shoald b O
cLar>cu str
~ . o! auto i:~*:~~ny.
~ ~ ~ i4. Ddaiden
.a
~ a ~ 75. Blrthplaee
~/C ~x,. I! dealh was duo to ezteznal causes. Lll Sa tLe foItow-ing:
" 16. Inlozmant'Y~ Slgna y U ~'W '~L?'Ya) (Probably) ACCldcnt„ suicid~ homiddC (s :tY~
+ 16 (al Addr!~ ~ ~ h(b) Date ot oCCUrrcn~0
• (c) Where dld WmY oMa?
17. Burtal. crematfon or renwval ' ' (Clty or tovra) <Coucty) tState)
17 (a) Da*~ l7 fb) Pl ~aoa~~•./ . (d) D:d Sc?i~Y occur ia or about Lome. on farm. in 3adustrial p3ace.
l;' , ~ - ~ fn publlo D~Z
18. flinerai fllrecWrs Slanatur (SD~~Y tYDe ~ D~i
V. S. No. 4 tE (a) Addr _~•C~ ~Yhf2a at w (e) bteaa~ ot .fp~w~'
~ / 2.3. SlSoatt~re - - 'i,r.~C.rc, ~t. r'J.
~ ~*ue~ ~ 1 y3 ~ I Ite8lstrar , (a) Address - pi(.1-~tt •~n.~ /
FiL~4 ~`Y f A. •a~~.~.. . F
57 . t!J : t ~ ~1~ ~ ~5 . . , . ~ , - , '
1 ha~by awtify thb b oo e rrw and corr~ copy of tM t~oco~ ~~G:"~ =;,ss" COUR~ ~ ' ,
~ r_,. ``~:Ii 1 J i~'
~ R~pistrors record on file in tha St. lucie Gounry Hselth OooeR-F:r.r.a" ~
= rtwnt et Fort Piwce. Florida. ~ 2~ f 7 ~ • ; . . ' ~ ~ l,
= -
pu~ r6 ~ , -
ami Not valid unless ra~sed feal of ~ha St. L~ci~ ~ s' ~
~ ~ County HeaNh Department is affixed.) . _ _ f . ~
~ ' ~ ' J _ :
~ 2.894U4 ~ .
~ - , ''r~.?: • a
N. D. MIIIER, M. b •
J~/,r~ 1 _ i~,~~~
~ y~Hailth Offiur 6 Rhistter ~ t Y 01,
~ _ ~ _ ; .
~ ~y -
~ ~ p~uty Loui Q~oisiror
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~ gooK2~30 ~~~E274~
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