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HomeMy WebLinkAbout2601 3Q~~04 ~ r"'• ~TATt ~a• w Miw~r+ C:.iRTIFICATE OF DEATH fO~~~ ~ ~UN[AY O? V~TAL• ~TAI'IfT1C~ fTAt~ FIL~ NO. FLORIDA erd •~ew ~BIRTN NO. pr~p~rl~ RE6 NAR'• NO. 3 •a~e~t~~ ~~C~v KATM GOD[ NO. L YWAI 11[NKNC~I~M~Mrali.d_ f/:w:w~.w: R~:I~.wN.~..i:rN.) •n~ •111 STATE Gpy11TV s. ~i.e•e ' L ~ _ • a i n . yr- aTr. ~owu. o~ wu?TaN ~5 ~I.~CE Oi OEATM c. uTr. TowN. oe ~ou?T~ K IIES~O[MCE •~r~~t ~ u4~0E C~7Y UM~TS~ ~NS~OE C~tr Ur~TSt '11~. . ~ YES NO? i~ r~ r[S~] ~p? 1. IU1Mf O~ l//~( ~~]yr. ~ y~~ y~~~) IEMGTN OI I. STR[ET AOORES3 NOSMTAI OA 011 A FA~Yf MSTITUTqI~ rt.Pierce ~em. Hosp. 3~T'~'~:~ 123 t~orth llth. Street YES? ~op wAM[ o~ fYrN N1ffb Lw wiE Xwf~ Dqr Yr~ Ott[A{i~ ~~p«,.~.r~ Yary Beatrice ;;c.`:anus ~TN fi 2t, I957 S-~ SEx OOlO~ O~ IIACC • M11~111E0 ? hE11[~ MMRKO DAT[ O/ NIITN A6E Ktl1 1! UNDE~ 1 Y W UMO[~ t~ wK. . • e . 'remale khite 1it0~`~'~~ rnowreo~j awna~ Feb. 21~ 1~ff~0 77 p l~ f~ l~ IO~. USU~I OtCU~AT~Ow (OM~ !id ~J~n?k 4~e IOA. K~NOOi NlSIMESS OR WdJST111 11. ~MITMrIACE Ibldf /Mt1A ~'MUl?~) . Mvf~ 0I ~W1T C011M111f ~ .,~A ~ ...~y...~~,.rw.a~lJrNMeA ••~••e ~o~aestic i3el~fum li.S.A. ll~~t lwk 1~. /ATM(11'i IY1ME . 1~. YOTMEII'S MMDEII 11AM( •r •~v••?~s.. Alphonse r rere i~osalie Legrain is. ~a ocansco cvc~ M u. s ~~r[o ~onccs~ socu?~ sccw~n No. u. ~wrowM s s~a~?Tw~ ates, 1/r. r~ Ow~rwl 1/1 M. w~ M4~ ~ww~l . wu?... . Lerce, ori a ~un~1~l 1~. CAYK N~[ATN ~61tp wl/ ~st pw ys? li~t/r (A). ~(tl.) INTEIIYAL tETMEEN ~AIIT L OE~TN MAS GUS[O ~rr pEATN °1tiet~~ ~M~p~n ~ Ceraoral he.TOrrha~e ~~ji~~ .~.a r~i. ee. .•r- c i r~ e.~• c.,~rt~u. ry..r. ouc ro N) . .~e~ t~• r~k?~.r~. r• ~ l • • • 1 ~ ~ ~ ~4r- . r~st~t?ar lI~M nr~r 1~M. ~ TO (d ~ . •ItAlw ~1 ~ . ~out f- ?AIIT M. Ot~Ew S~CI~/~CMI CaMO~TqwS COMIMMlfM 10 OGT1/1R M0~ RCIAt[O 70 M TfRrYMI DIS4f[ 001101101~ GwF11 IM fYi 1(~l . WAS AUTOKY F ~[IlipllMED7 t~~ A~~tA S 1f[S? MOO ~ ~ 1 e • ~ 1~ h?• ~p. ~K~~ ~ ~U11Y OCCWUlEO. (6~ln w~fwa • •~k~wt ~w~ ~ ACCIOENT SUK~OE NpMICip( /~IbPe~IrArelJyth~l~J ` aWJ ? ? A~ ~ 20e TU~E Of !/wr Xwt1, pI. Yr~r , wuRr . o W = IO/. IMJUIIY OCCYR11E0 m?. ?LACE Oi IN/U11Y iw ~r dyrf Nwt. m/. pTY. TpMM. OI! LOG71011 ODUNT? STATf MNK[ A7 Q NOT MNiI[ ~ w~. ~~MI. If~tp. Nk. er4.. tft.) 1MOAK AT 1rO11K k 21- I~rt~nd~d tM d~w~wd /rom 191,9 . to lyri7 •nd /ut wrr A/m di~~ on ~Cij : ~~~A m o~ tA~ d~t~ ~t~t~d ~bo?~; ~nd to tA~ bNt e/ aqr kno~rNdp. /ro~n ~A~ s.~uN~ ~t~t~d. • 11 1 t~~• No~1YRt (prMn M fYk) 71A. ADWtESS •r• N 1• 71t. WTESIGNEO `••,'•c• • °irhar~ r Sinnott ~'.ii• GEi S, bth. t't. Pierce t~-2!~_ •et11?~t~. ~M~T~. ~~T[ Zk• MAYE Of tEMETEIIY OR C11[MATOIIY j3/. ~p(.ATIOM (Cif/. (N?R. M~Nt~!/) I~~k) ~ a~o+rw (Syny~l ` • Bvr: 1 H-26- H't. C ierce Ce-~eLe rt. Yierce Florida ' y•S•~A}S j{, fU11E11KOMt OII"3SKMATYII[ AOORESS 2S. OATE IIECO. ~Y IOCAL IIEC, ~i. IIEGKTMl1'S SIGIIATYIIE , ""''°O~ .Toseoh '+J. Yates t. Pierce i~ ia. 8..27.~_ ! p L . r /ILEC aa: ?Ecv;UEO . ST.IUC•c ~ )~hfr FIA. , RO~:: ~ ;~.:~iR~S f(,EFK ;;Ji~ C4URT ~ s arri;p.. : Q_j~~ ~ 1 n~nby oortify thia ~o 0o e trw and corr~ct copy of tM Locei ...._7~r Rvgi~lrels retotd on f+le i~ t1w St, lucie Gounry H~a11h D~sR• , rrwnt ~t foA Vi~~ce. Fbrida- A~~ I 4s YN • _ . ~~~i?1i~l~.~ (VIlemi~y: Not va~~d unless ra~s~i seal uf th~ St. Lrxi~ /~c Cpunry Heahh Departme~t is effixod.) ~Vp~Q~ - u : • - > ~ . ~ ' ~ _ : _ . ~ _ N. D. MIIIER. M. : ` . r Co~n"~y Nwith Offiur 6 Local Roqistr~r r ~ ~ , a' , ~ - • i~_ ~ . ; ~ ; ~ / ~ , / -e~ 7~ 7 ~ w lt~,n C~fLv ~ - ~ , _ p~pr popufy t,oul Rro~strer . . ~ ~ ~ ~ ~ ~ B~OK~rW P~i{~~V~ _ ~ ~ ; • ~ • . . - ~ . . ~ ~ ~ , ~ ~ ~ ~~~a - ~ _ ~ ~ _ _ .a. .c ~ _ ~ ~