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HomeMy WebLinkAbout0791 ~ F ~~p ~qp RECOR~EO i{. UC1E COUM?Y lA. 2c~1~iZ?~ CLEitK C~~GU~ aC0111tT ` ~ pECORO vEH~F~E~~ 5 9 s9 ~N'16 - 32~1123 . _ . ~ ~ ~ . . - _ . , CERTIFICATE 4F DEA?H ~~..~.K.~ ~ k.l~~ .~a R~b.~~u.n„~ ~.+n. F L O A I D A srwT~ ~~~s No. ~~~~.cu?n ~a..i rn '+!t. OR ?lIN1 IN i°"°w"~4n•^^iO II~OI~T11A11'• NO. sI~MANINi INK N?~D100[ i01 ~E ~ •~y~ r~0at li OA/E Of DEAM ~ rOwtM, ~~t, q~~ ~ ~Minuaars , ::t):~:;_iI.t_ .._..C'i! I ~ ;1~11 , Gctober 6 197a U?CE ..~n. N~OW. W~\K~l1 IN~~?M~ AGE-uN w~e~ ~ n.~ wa~ Q~t! O~ MRtM ~.w.~w. wr. COIlNri O~ OEAT11 ~ ItC /fMCMt1 M{t11~A! 1~~~~~1 rp~, Mt! MOY~! rM. ~~1 - ~ x • .IliitQ G~ s ~ ~.'.u .19 1~10 Indizn t'iver Cm, tOw~+, OR l 1 _Atn r.ww em .r~n ?qSM~I OQ OMEt NSt - ~r Ma w uw~, a~n ~nen .tiwn i ~ncvs w «o w ~'cro ::c:~ ch :!c~ 'i:'-s L::~~cl C~s lo l:oacl-t!est :~icle Inc3. 1 zv ~ SI~iE W WM ~w ror w tmza+ d w~ut touNi~r MAt~IfO. NEVEf MARMEO. tURYNNG S~OIiS! ~r ~rr~. o~w w~ew ~wr ~ cow.w~ ~ wIDOwEO. WrpKEQ i wun ~ ~w..,+e+aMte 1 1_ ,;i:i:.C:1I1~CL't:: • ~):iil N i.:~11J_CCI 11 TiQ~l].C J~QVCIIS ~ ~•ne eeu.f~o „ n.n. SOCuI SECUdfY MIWE~ USU~I OKWAt10N ~ aw arN or .o.a eow owMO rw~ a itl~D O~ MJSwESS OR YOYS~R~ o..~..~o wwcr+o un. eqw w amn ~ nn8 -03 -1994 ~a .e ~ .,,~.~;..~bK „ cstmer c?~~crltor t' ~1i1 nlllc Stora c-~.~.c« RESIDENCE-StA/E C01NRY (IT11, TOWN, OR IOCATION w~ ts~ ~rw~ S~REIi ! ~wcr. n~ o~ w ~~.,'1o1--~c,z ~a I.ucie i~or1: Pi.erce ~a;`o. 1~~ Im erial ~!a fATMER-NAM[ lvft rroa! 1nq MOT1~R-MAbEN NAIME Ir~t rMp~ W/ ~ ~ Cla~-ez~co ::ei.tli Lliristie ;;r.iitli ~ INIOUMANi-NAME MAING AODRESS ~3nflt W~.?.~. MO.. dh p Mr+w, n~~t, tr1 ~ ~ u. ~:1-s. :'ell~.e I:cith ~ra7.:•.^. Ti~ne~-ia1 i1~1~~ rt. 1'iercc ^.la 3.-^.~~0 ?~ur ~ otwt?~ w~s uus[o ~r: ~c?+rt~ a+ir orrt uust tr~ ir+c rw (o~, ni ~w ~~n ..~.e.« o«s..:w ...w~ ~j - ~..ro..n u Consistent with acute myocardial infarction . . . ~,~a„,;~;p Radiating chest pain syndrome j ~rrlO~~it C~Y1~ ~ « ~ ~u~~, lt~t1M6 t/1f YN~~F ~tIMO C~YU l~ft f ~ntT ~ OiNER S1GNIfICANT CONOIT~Of15: co.~na+s tawwNuw q~enr wr nw rua~ ro uvu o~rer r riun ~+u AUtdS11 r ~E! wu~ nMaMo~ eo~ ' ~n~ w Mo~ ~~NM wuWwuw uoN Has refused fami 1 re uest to ns 1 ~ wCGDENi ~ ~ ~..w~¦, ~rr, ~eu ~ 110Ut 1pW IN1VR~ OCCtIlRE~ ~ eMq~ wtir a erwn ~w rur ~ o~ r.n u, aer ~ Ot IJ~O~ttWwEp ~"MNatural M ~N1t~r ~l wOR~c ~u?CE OF R11u~11.~ row. iuen, ~.nm. lOt~i10N ~ sn~n o~ wo., an w ro.~., s..n ~ ~ snnn n s o~ ..o ~ owKe wa., uc ~ wan ~ 7~ 7M AI CERikKwiqN- ra.rw n.~ ra.r e•~ •w ur w~ s.r «riwn wn w~ w/~~ w~ ru~r wy otwiM Ottvuto wt ?u,u. w ey ~'I rNr3K~. '~~wt~ tw TO rO~+~w a~• ~W ~Oe~ ~ne~ ~1.4. ~wdM~ NU. ~.o. q w ~eu Or r~ ~wv~leoe. ~M H~_ w<e.uo ~~o.. Ift~ tl~ )11 24 NL ~o nr uw~e~f~ sw~~ E CERiYKJ~iION-MEpICAI E7fAMM1ER ~ORp~H o.. ny usn a~w row a a.a nu Ncea.n w.i r~w ~y ~ t~~rw•tqN W rwf ~01r ~M/q tM w~rNtq~r.pw, w rr prwqw. ~pq1M y?; r~a~ ~ Of~n~ [WM O~+ 0~4 ~MO OM ~O N1! 4VYH! ft~RO t* ~te~i a~ -Examiner---- ~Q.~- ~ :5Q a M CEtilflEf-N~~me o~ r~wn IURt we1 n D~.w.u~, wriw~ u ~ n. . Schofield,Jr.,M.D. • , . ' ~ ~ i ; 1 -6-75 ~LL~ A~OQRESS-Cft?YrtR f*re~ w~..~. ~,n p~ ~v,. ~q ~y O~~ ~URtAI. CRfMAl1pN. ~fMpVAI G~Etttv pR CREw?TWI~-NNwE lOUiION . u~ a~ ~o.r.. sun ~ sMtu~ ~ t4 ~.~'c:t^:~' i:._()11 N~ 1~~: • 1~? C~,'l:(? C:i~C3:l~l~:O:i V tk 1''~: • 1'].Cl'CL' 1:1 DA1E ~ tw p~~, r~~~~ iUNEfAI MOME-NAMf ANO ApORESS ~ f~tlft W~ Mp., p~ tOrM, {f~M, I~I ~ ~u : ;or!e "O`c '777 ' ' ~ ~ _ 10-•1~15 ~e.. «~~e . -~l i~ t . Pzerce . ia. ~O ~G 12 ~uNEW O~EC~c~-SK r aEG+st A SlGNAiURE ~ wR !!ClivED ~OC1y ltG~S1U~ ~ K p . ~,o : . , - E-E-r.c~- .t ~ v1L~~~;cwvc ct r~ _ ~o tw . ~ - 6 -r,- a ~ ~~I hereby certify the above to be a true and correct copy . ~ of the local registrar's record on file in the Indian River County Health Department at Vero Beach, Florida." ; ~ This is not valid unless the raised seal of the Indian : ~ River County Health ~Department is affixed. _ ' ~,.~~~1, , . ~ ; ` ~ull:: f } 11~ n, ~ _ 4 ti7 ~ ~ > : ` • _ . . ~ ~ ~J~ , . ~ ~ - . ~ , , . ~ : - ~ ,y: . ~ ~ ; ^ County Heal th Dir. , Registrar ~ , ~ ; - ~7 ~ , L ~ _ . : . 'z~ • : . ~ f ~ J- c~% ~ f~~Yt C ~ ~ ( ~ ' ~ Deruty Registrar ~ ~ ~7~~ •:.::,Y~~i;...'` 'y 1 Y,~'~ ' ~ 1 ~ - a~~K~~~7 ?9~. ~ _ ~ - - ~ ~ - ~ ~ ~ ~ _ - - ~ - ` _