HomeMy WebLinkAbout0707 , , - ~ : . ~;Q~98`~ - ~ ~
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~ GERTIFICATE OF DEATH
f ~ ~ ~-f ~[~~f`~ rrwTi r~~~ No.
' FL08IDA '
qE(i18TRAR'8 NO.
BIRTH NO.
.1. PLAGE OF DEATH cou~ No• y USUAL RESIDENGE t~.•+~«..+n..a u~..uu~w:n.+~+~
COUNTY STATE ~ COUNTY
St. Lucie bh-1?_ .larida St. Lucie
B s. a~r ~~c .r.~.. a..K.~. u.~K aw~.~ c. LEN6TH OF cin w.ww e..«w w~~. •~u avw.?
STAY lu uu i+wi OR
o . . rown r't Pierce
W towN r t Pie i~ s ur
~ d. FULI NAME OF Itt rt N~~~~M. M"'~ ~w ~ d. STtEET
r t"~J11 • HOS?ITAlO~ T u ADDtEii 1•an il V6" ~I'.
" INSTITUiION !
i 'n'~
Ila~t/ L DATE OloatLl (D~v1 (Y~)
NAME OF /rint) k ~Y~'~
W ~ DECEASED ~ ~T OF
~ (TYD~MPriwt) ~ aer ~~TM I.sar IO 1~2
~ ~ S~ ~ CO10~ O~ MAIIIED, NEYER MAlRiEO, DATi OF ~I~TH A6E ~L v~~m ~~w n ~~N~ u m
w~~ow~, arroac,~o ~e..•u» r•~ •~•~v? ~ D.,~. u... x~.
b a~ ~ . J - 8dl 0
' ~ 10~. USUAL OCCU?ATIOWm~. tt.~ d M Nb• KIND OF WSINESf O~ IN- It. ~ItTH/LACE Ieuu ~r a~.~a «..~n1 IL CIMEN OF WHAT
ousT~r * COUHTIs a_
C~ ~er ~ r.. +.tl.s ...t.t ..~t~r uh~ Y e~tlna! ~ P O v Y7 8 1 l~: . \i . v. .
y :1 '
R w 0. Il FAiHEt'S NA11i N. MOiHER'S WIDEN NAME
M ~ »'7.-, n 1 • •
~ . ~
(Y3 ~~,,,~s~ IS. WAS DEGEASED rEt IN U. S.AIMED FORCEi1 I~. SOCIAI SECUtITY 17. IMFO~MANTS S~6NATUlE JO~jj'] i'~C ~i AI't'.'~~f ~
~~y~ liw, r„ ~r resrsl IIf sw rM ~t R r1M H ~nb) `t NO. ADORESS 1'
a MBDICAL CERTIFICATION ~INT[RVAL ~tTN[IM
~.v~ ~ 1~. CAUSE Of DEATH ~ oN ~o o~wn~
• v Ealer oab e~~ e~a~e DISEASE OR CONDITtON ~4~ , -r
, 1a ~ li~ lx l~l. ll). CIIECTIY LEADINC TO DEATFi'(~
~ ~.d N,nc~oerr cwusFS ar.ci tf a~ s
o ~l7us dw~ +we Msriii awiiKow~. il ~ti. 0~+~+~1DUi TO (b
~ ~ tA~ wol~ d~Y~*I. riw b tA~ sbr~ eaw~ (s1 ~tsh
~se1? u 1us?t /~iirn.•• esw 7wt.
utAewia. ~ta !t w~s~u ~"o ~ DUE TO c
~ O tA~ 1i~tuR iwjsry.
i M~~ ~~yyti~~ ~ A t~ A OTHER S16NIFICANT CONDITIOHS I
I ' V D0 ~ c+...e1 1ntk. C,wl;e:.w, oo.erie~tiR/ a W. 1rstJ. b.e .ee
nLted te tll~ di~eaw ~r oswdltiow ~swiw d~atA. AYTOISYi
~ ~ q~ Ifa DATE Of O~O
-N ~1b. MAJOt FfNDIH6f OF O?EtATiON
~ rt{ ~ NO ~
t ~ Ip,y,aetyl lewelt~/ 2ib. ?LACE OF IN~UIIY tws.. l~.r ~iaat 210 (CITY OR TOWN (COUNiY) (STATEI
~ 1 ~ 1~~. ACCID[NT Yr. hr~ beMr1. ~tnM. Me~ ~Mi. ~ta 1 it e~~l. N~Y HQR~Id
d ww~o[ !
1 ~ Ild. TIME I~U ln.s) Iirr) lewrl Ilw INJURY OCCU~ED 21 HOW 010 INJUR OGCUli
~ wO OF ~MlliAf MOT~MIti
~ INJURY ~ ¦ou ? ar ro~a ?
~ a 7 " 1 c~ 0_ 1p_, to ~•_..~r+.~r? 19 thae I latt sow the deccased
S ~ u. I hcrcby urli(y thae l altended !he deccaaed /rom
n1;,,r nn • f and Ihot dcn~h oceurrcd n~ m.. /rom tha eauaca and os the date ata~ed above.
~ ~ t~.. SIGNATURE ~n.s••w or uw) . ub. 2Iu DATE SI6NE0
T TJ ~ ~ C~
v~ . 'i chr rd H Sinno ~,t - ~~6 S G, r • ~
o N~. ~ U~ 1 A l, CREMA- N?. DATi 31c. NAME OF GEMETERY OR GREMATOtr IW. lOG?T~ON (IXtf, to~.. or eoae~71 (SVk1
TION,~EMO;AL eMeu» ~t ~ ~~Q],I1"iS (it3T'.e3t6i ~f Ankona 1`~1&•
~ FUNEt11L DIIECTOt'S SI6NATU~E
DATE tEC'D ~Y IOCAL 1E615TRAt'S S16NATURfe
, ~ _20-5~"~' Ani ta r~ichar6son u. r. Joseph w. Yatc:s r t. Yi~:rce
~ .
~ ~Hp kEC0R0E0
f~~EO ~auNtr fU•
~
~ • ST.I~~~`•-- t :,titAAS ~ : ;
i mb ro bo s rn,..nd corr.a ooPY of tn. wu+~ ~F~ C~'~J1~ COUitT ~
I h~nbY ~tt fY ' ~
Rvpi~tre/s record on file in t1w St. lucie Gou~ty H~el~h O~aR~ AECO~C'~F- -tF0 l~jiil-~4'r; < <
1fWf1t N FOA PiNCe. Florida. D11 ~~5 : l;~ j:;' i
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~ (yyaMiny: Not vM~d unless ra~s~xi sea{ uf th~ St. l~Ki~ ' ' , ; . ~ ~ - -
Cpunty He~Hh Oepartment is effixod.) ~ .
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~ . ~ ~ , ~ lY;~ S
~ N. MIIIER, M. O. ~~p ; " ~ y ' . .
IM Offtur 6 tncs~ R~qi:nw '~78~ '~j : ~ii1 ~0 3 • I
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~ ~ poputy Loul R~o1str~r
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~ 600K ~?JV PAGE 7OT
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