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HomeMy WebLinkAbout1776 . - - - . I - - ~ - 3~~~.6 Cr. iFICATE OF D~ATH ~tprA~.u! ~f H~~i~6 ~nd n.~aL~'..:alire Jerrkn STAT6 FILC NO. ~µ~:~10\ OF t4_US~t F L O R I D A REGI6TNAR'S TIO. 5%= ti,...r m.. n.trnn iYi[. Op illt.; IN ?iRMAK£71~ INK- ~ ~._~r .wa~ :~st 5~x ~OwTE Of DEAM ~~Jwlw, D~~, ~1~~ ~ SEE Iw~::~Ot F~t ~t_EwSEO-..~•~l ~T~a~s ~ ~t,'~SLLI. Ra`>^::~`:D SCt:'_'L'_":' : ::ale October 4, ? ~~73 RACE rYU!e. ~uGq. uuaK..~. .w:.-~AGE-ul~ _T••oe~ • e.• ~ D~iE Of LUtTM ~.a.rr, O~r. CQ~Nn Oi OfATM •.~ini~~l':~rS.~~r,~.S . WTf ..^~~s fWl ~ ~1C- ~ Vt[~n: ~ ; ' . :~:1:it e u2 u i i ~.~ent e.i 3 1911 Saint I.~:cie ~:i~2 1^/. TOM/\ Ot ICYA•li, . Af OEAM a: c~ .~+~n M. ShTA~ OA GiMER WSTILUTION-NAME ~u w~ ~M u~~~, eM atue~ uo rwut~ ~ ~ f~.u~. .es o~ ~+O n ~~rt Pierc-e Yes T~ ~'ort :'i2rce ~:e^:or;.al !3os~.ital S!aTE 3F ![Th ~ u..o~ r w.r~ ,-EN J! .rMi CCUNi1tY ~•~t~:F::. ?.tE~~Ek w~tR:ED. SURVNNG SPOUSE ~ ~ r~R. OM ..~~Ofu w~re ~ • u,~.~~ ~ ~ i WIOOWE^_ Div:;CCED . v[cr~ ~ c. ~ ~ x~ ed Rose Lar.ber ~ uwu ~u~w.::~ ~ ~~'l2.^. et t..~:1 ~ v~tu eeCe~sa~ S«W SfC'.fli .-'-~:1 ~_Al OCC':~ATIO': ::r~ awD O~•wue uW.i o.~.M. +c.u W KWO Of WSWESS OR INDUSTtY l~~lD. N Ol~Cf ~ r0~~1M0 ~eh. t1~IM ~i _t~.~lfY 1 OiCYtllO W ~ L~ snrut~o...cm ~~-27~t -03-.:;:i4J iia. PY:.CL:C`L3•=~T2 1A }ZL2v Ci~ uw+aa.~o~.N~ RE:IDENCf-StAiE ''.rt•' ~UTf, TOWN, OR L:UT:O`. wwe an iru~s STREEi AN~ NUwyER ~ v~u~e ~u w .a ~ • u_ ~ t~ I•c.+C+ ~ t~{~~ n t'<, ,n ;~i ~u ~:C: h~.l l l Cc~ yf3Tla Ct o ~'S1, • Xl~.'~ _ _ ~ fATnfR-NAME ~:c.~ rwae µ'v:tifR-nu~:N NnME ~w~ ..:oou us~ u Geor e Sch~~lt%: ?es~;_a INfORMAt~ti-NAME I~+~AYYiG AOGRFSS ~stu~+u ~.r.o- wo., cm o~ rov.~. sr.n. ir~ v. Zo~e i Sch~•ltz ~nl~ 1 C'act.~na C't ~t Pi.~Yce ~7 !1 ....r.~.., /~RT 1. pEAifl Ww5 CANSEO ~Y: IENTEt Ot~/IY ONf UUSE If~ IYJE fOt (o~, (e}, ~HD (~I: .~~r~.u.. o~s~t ~rw oe.rw 1~. r..ro..a cws~ I 1 NI ~ Y~i.~~r ~Vri « ~~'f•~ C.i.? U • ~ O~! ! 1: . ' co..o~~io.s. ~.n. ~~~.~J tr'~ ~ 7i ~-~c r.~er e.rt ua eo J f01 ~,k,(.{~w. t . ~..~o~.~~ e•ufe ~e~, ~ wa w. o~ •s . ca.s~ow~.tt a: ~ sr.~~r.c ~w~ VMO~~- ~~INO CAVi~ uft ~~t ~ fAtT M. OTHfI SIGN1fKwNi C01iWT10N1: ca+auo..s co.rtw~r...e w ot•rw w~ ~oi nu~no ~o uuu e~.en w rur ~ a~ wUTO?SY ~f ~ES ~i~e ~~~o~res eo~- O~ OIwtMM Oftl~r•MU~G UYlk ~ Ih IK - (j.oyoptt1 wCC1pENT. SUtC~DE O! A E W1 ~+a+~w, w~. n.~ i HOIfR ~HOW INIURY OCCIilRED ~l~.re~ i+.rwe d INlYN 1ti ~~~t 1 q I~~i n~ ~ru. ~ ~qir~;lOEa pl yNpEif4?Y+ED ~ ~ 70?. 2C[. M ~ ?Od ~ snttr, r.c*o~., r ~ INIUiY AT WORK nwCE Of wxbtr.. w..e. iOCwnOr~ i s un o~ ~.~.s. .w.. e~n o~ ~o~~, s*.n ~ i ~ ssec~n .~s a r.o~ ow~ea ~.,ne. ~sncrr~ ~ . ~t ~ ~ C CERTY~UT~Or+- .~o..+w w~ ~w ro..m o.. •iu 1u+O VSt SI~V Mw/14~ Y~`~! OM ~ uW/Da wOt v~tv Ml DEwTN OCGUVED .i n.~ w.ce. o.. ~N13Kun: TO ra.n~ wr ~[N ~oo~ •m~ ot•m. ~wou~t o. r: ~vue c~e ~.~~.~t~ io 22 ~n ~ ~0 4 ~3 lo ~ ~3 a~a y, ~3D~ M r0 fwe e.wu~a~ ir•~e~. ~ 7~~ oeee.seo r~o.. CERT~f~UT10N-MED~CwI EtM~WER Ot CORO?~Et: o~ rwe ~+s~s o~ *we ~ov~ o~ w.r. ~+t ~ea~* .~.s r~ww.~c.eo oewo furw~rww O~ n~t WO~ uw/W iwf rnllt~Wt~0.1. w rr WwKK.. rO~tN o~~ ~7e~~ wou~ ! ~ O~~M OCCUYEO Ow 1y W/t u~0 OV! ~O M! 4YSl~fl st~1lO. M. 17` O 4 M [ 7?~ ; ` CERTIFIER-wIME ~~~t o~ r~wn ~ S wTURE wo te oa rm[ OATE SIGNED ~+o~T~. n•~. ~eu~ ~ William H. vie er, v1. D. , FACS ~ lC~c~.~ Y ti... 10-5-73 ~ru~~ oa o. ..o. em O~ w... 1s~re tv , i~~ort~`i~`~I St. Fort Pier e Fl. 33450 ~UIUAI. CtEMAT10N. RfMOVAI fMETER~ OQ CRFMATORY-NAA+f LOUTiON an w wvr.. uwt[ ~ t~KUr ~ n , Cremation 2~~ [ ~u i 1~=~v'~- C+`~- '~~'~11 ~ +`0-L Piercz Flori~a ~ ; DATE~ ...w/~n, w•, n.n fUNE2wl MO~.~E-r~~tw~E wND wDDRf55 : sin[t O~ ~.~.o. .w.. an o~ ror.., fuie, iu ~ • :u Ci~7` ~ / 7 ,s. I'ates - :in e~a 1 '.-'.o:,~e , Lo>_ 777 I't o ?ierce , ~1 33=: ~7 ~ V. 5. r612 it~Elu? OuECiO~~x ~`j~ ' tt~GiSt a-src•r:~tuQe OAtE ~ECE~v[O ~11 IOCU ~FGIStu~ R~Y. 1970 7y~ `i~~r~-C/i 7~:~'C-~ ;w e ~ riS ^..•?i11'.~•~ a ~ ~ ~ fIIEU aECi~~EO Si.tUC~`- ~.NLyTY flA. ~ . ~ ( heNby oortify this to be a true snd Cotrocf copy of the Gocal Rp~:" a,,iT~AS t ; Royfstrors rsaord on file In tfie Si. Lutts Counry Hoakfi Ocpert ~~Ekr• ;;-•Ci;IT CO~RT' ~ ~ - ment et FoA Pieres. Florlde. qc(;t i?~, `r _F"r~f ~ _ ' s (VVarning: Not valid unlecc rai~d ual of tfie St. Luci~ Q ~ } - County ~Heaith Oepa~tment- is affixedJ ~v ia 15 aK ~5 . ti~ ~ ' ~,7~!l,~~~l~ i • N. D. MIIIER, M. D. ' r = ~ 3 ty Nealth Officet ~ locel Rogistrar (]L•~~ ~ • . . : ~ _ 3 ~a _ b ' ~ 3 ~ /!n, r~d 1L~~ ` G~ V v . , • ~ p~~ ~JeptAY ~~te! Reai.r.,~. ' ' ~ i ~A~~•' - t ~3 ~ . ~ . - ~ ~ k ~ BOOK~.t70 PA~~7~ ~ ~ ~ ~ a: , ' ""n"_ *,s.. y"'.:~K a_ ~ ~r u,: ` ' i`~ . . ~ , ~ : _ u`~~$__-- , -