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HomeMy WebLinkAbout0217 . 39003`7 / ~ cf State of Fiorida cER-ri~icn-~~~ : or- nr-_n~~t ~ Ikpa?tnxnt ol He~lth ~nd Rehabililati~~ ~ry1Cla 91~7r rii ~ no , ` VITAL BTATl31'IC8 L,O R I D A nr•:~atn~a s r~~ TVPE C1R PRINT 01CIA7EO-NWI nn,c.~ -'`r~i~ .v ty~rr~ . s-l2'l~L_ PERMANENT ~ 1L~ZY - - LliC1:3 Plale -UGC~~trb~~_ ;u 9LACK INK ~ACE .~7. rt6q. ~•~~~car wM~a, AG( -t.t~ u.Mt~ . .r.• ~u..o~r . ~ [~~I! ['1 ~i~~N '(MMIIV ~N M~iN ~K ~Wt~1t~ M~~W~.,q~N~ rOf ~.ry ~.~dnf v.~. 6t.~2 ~ Dlack -5Q - " I--~~ t' ~r , ? 1 ~)?'J_~,. S t_._Lttc i e- ' CI~. IOMM. O~ 10~~i~ O'~~;N n.fet cw. ~r.rf NOS/~lAl O~ 01Nt\ NStftU1KM~ N?Mf .r.. ~.~.n• :~n .~+e •.w.~~~ ~ . _ 1~ItM~ ~i{ W MO ~ Fort Pierce Yes I~ 1:.I'_icr4c 1~c:moria.l. Iio~.~~i tal ~ St%Tf O~ WM IN MO~ w CIhjIN O~ MhUf ~QU~I~I MA~~KD. NlYU NA~~4P ahvrv~~. tnr~~f COM~w~ ~ WK~O~"/f D DIW)ICIO ~ Y/t r. ~ ~•~v..a~M+~r ~--~oxida. . U~S~~~ N~1:lI I'l<'(~ ~n ~Z~'Tl%1 r~t.l[.I.;t3/ .rtn thlay~ r M~w SOCIAI SICVMII MW~1~ ' USUA1 OCCU~Ailptd ~w.1 ~+we o~ ~.0~~ M~.~ ow~~+o ..7N M ~~MMI CM HItM45t M Irrp~nlRr octMM~ M ~O~M6 HM. I~~w w Nn~M ~ - ~~264 32 8686 PIinister ~:t,~~rc}~ .IVNwI~ M~OM . . . wefor - - - - ~ - - ~ - ~ - c~.. an11t ~i~0 r+Vw~l~ ~t3Wf~K!-St~t! ~ COVNt~ fhr, t0~+. O~ tIXwnC~r~ , Florida S I, c ' I~ort Y' r~~ce ~ ~~..~Yr n . 102 A . _-_~__,1 _ MI?k~-N1M( ~r~f~ r.pp~ IMOT~N•. M~MNNN.IW rqp n 1 ^ ._.iic..11~I:iG~....~~s~i.iS:.(2~?=~ IN~OMAAMI-N1M! MA11~K. AUf ~tSS ~ ~~r~r~. t.~ ~ r • o~ ~ t•.n. . v. Rena LUCal3 ~n j1n:_' A,l~. i~'l:, ]'it~r•~~~~ f~l.~.. j;11'~(1 ?VT ! OtAM ww3 GUS[D ~1 ~(?atte O?wr r~rM r~u~1 ~I~ ~'R ~el •~+t~ c~p u.,o+~ow.._s~ N - - - - - - - . M, c~ ~ o ~~5~~~,,j,-~~ - - - - - - - .u-~s . r a~ - - - - cor~n~o..s, N 1M n~~O~C~C"~~CJ I-rL'-1~`_r,~) ~~~1~~~ ~V C ~otr ~~q u?~ ~ ~ 11) ~r~IN~M C~W~ ~M. ~~0~~~ ~ t YOV~M[f d~ I b~bN~ tq ~r~N~ - p~M~ (~~M l~it ' ~ ~A~t ~ OT?K~ S~NMKANI CO~11Q~S- CO+iMwbH (O+MVNMO q M•,. ~ur wOr Nuq~ ~O c•vs~ n..tr w~~n . nr ~tUtqlW q r f: ~~.r ~..w ~ h~ rI~ wn~ Ve~~10 ~r~ 0~I~1~~ux~~f ~~V\~ M ~~~Iy A~ O ~w ? iCC~biyT IU~~Bi ~'~E i~CaN1W~'~.da.. i~•. •ra~~ NOIi~'-- t~~~~w uir~i~• rx ~ u~tit~ ~ r••~~~ •w.~ .v ~ ~ n~ r... ~ . wN~ p ~M~tIM~tO~ ~vi~ ~,~t io ~lse ~re_ b.7,~hroew~ ,~~r~~ 1~~ ~?;i ~'ti1~-N~ ~0 - 7 ~ ~~~_~~'~M~~•? - !?~UW? Af ~M'OV INIU~~~~ ~oM. r~~r. f~~ro, ~K*M~. IOCAOpN ~ a~rn o~ e «o . n.. ro~~. ~.•n ~ ~ I~~fCln tif M rO1 OMK~ YM.~~C ItM[M~~ ' h1v . 4 E ~ 31Ut~ ~Ve C~ ~~r.r,^ ~ ~E~~.,~~ ~-~cf('i1»- _ CERI1IKAt~ON- ~or~w ~ nu .o..w~ .~+e u~. .~~w~ .~~.r ew ~ e~eroro +w o~~tw Otew~to ~ ~1~tSKt~N~ i0 r?...r e~. n.~ ~os• ..m w.w. ~+nw• e.n ..w. ww ua ~ ~~MM~~ tw1 p~ 7 r. . ~~n..~ ov ~ fl~ s~a.f~s .~or fl~--- ti. ~~~__1. . ~ _ ' , ~ ~~fo" o ...y.,.. . - ~ - - - , , - CE~IMKAt10H-MlOK~1 ~l1JRY'1~~~ w~.~ ~.vs M rr ~~y/ ~ ei~ir»• ~:f .ww.:.w~~ e~•e . ~~~~w~~o~ M wy ~r ~r~/d n~ w~.lt~r.~•o.~. ar er~.~o~+. FOvv17 J~IMII~ w.+n. ~ r~. .r.• ~~~M Of[MM* ~~M • W C• ' tw _fi.~~~~_~t'~ _F~k"~itYt~,_Etr?-~j~rt~~ ~~~4'~-(M in ~7 1'M ~ C'tlMK~-i~/AW ~~.n oe •nr.r f SK:i~wtu~ ! ~ ~nr . w•,• ~oArr ti~..irr. ' ~,.~rM~tJ_ SB~!c~z- cAs~s-~Nh - l~. - . .r~. :,w MA~MIG ADO!!SS-CE\IM ! - -frnn o~ r i e ..n ( , t-. „ - - ~ U ~ ~ ~ f~, ti } r'~f~~_~_~'~ V.~ ~ ~ ~'r~tf~n :rj! ~ ~ 1 ~un~i. nrt.utaa. ~[.av~t tMtn~. wc~t.uur~.. .a.w iTi.K • - i e s.ter.. ~a Burial ~o Pine rri'OYC Cn"1C'~:~~r^, Ei~. j'n1'f; i'.Lnt'rn i+')nr'lrlsl OwiE .rw~ e s n.~~ IUNE~~I IIOM( ~u+,Y ~rtn ~CI~~r;S ~ - ~ • • c . , • • . Jan.7,1978 Stone I3~•of, ~,1't ~•i',.i,'., t', ~'t:. f_~ i,~~_-,,-~ i --1-------- V.S. #612 ! t Kl -SK.N1 J~ Ilt.~y .s ,cy.~.i.~~rs1 -%j ' - f:,.`•~ n.~~.n. ~.v.~ n~.~ ~ R~r. ~/7e t q ~l.(Q~(~_ ./~'rrl;G.~n._~.L'".•!i!il'i~?iY , t!~ i 4 ~ t i hereby cectity this lo be a true and cor~ect copy of ?he Lcx~+ Registrar's record on file in the St. L~cie Coumy Neallh Dea~ari- ment et For~ P~erce, Flo•~da. f ~!Q ANQ Yie LA s~. ~vc~e 6biAI~~ (Warning: Nol vaiid u~lecs raised seal of the St. Lucf~ ppg~R PpITRAS ~ Co~niy Heahh OeparimeM is af(ixed.) C! EFr :_ViT CC ~ ' - - _ ~r~ . N. D. MIIIER, M. D. 0 I~ 1; PN f~R , Countr H alth Officst b locel Reyistre~ ~ ~ 7 ~ u~ ~ ~ ' R ; . ONi DsWifY lOtaf Reaisr.~r ~ ~ . _ , ~ _ S ' •~l i . s(,~2~Q ~ ~7 t , _ ,