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HomeMy WebLinkAbout0077 ~ / St+~te of Flurid~ CER~fIFIC/1 ~ i:~~f ~ t H ~1 1 11 lk~~u?lo~enl Nc~llb utd Reh~bilil~lit~ .?rrirp~ YIAIf ?i~ c?u~ • vrrn~. STAT19'I'1(.4 F L O ti l t~ A , ftlf.l~.f1~~A S ~/1) T\PEORVf11N7 01CI~SlO -H ':i•'- •.~q`.~~Mii~i ~ INAURiCE D. 1(~II(~Cr~~V I ~GiPc• i,t~~~«~rt~,~ ~r~, 191R PFRMANENT - - - - - - - ~r ~ - - - - BIACK INK UC! ~+.N. ~~OM •NW~y ?GI . ~ ~ ~.c ~ v...... . ~ r,. , (~NII1 fV d~~H .•.w.... ...,t I t,6o2 • (vh~fe N 3y * - I~4~r~ 19.f0 ~t. luri~ 1F~ )OWM. fl~ 1~A~1~?j ~~~}N ,..w~ an. .r~n NUSnt~l M UpN~ Nt1~lUlKwf iiiu/ r~.r~ r.~.~ .i.~~: .rs rw.n~ 11~! ~~1 M Y[t ~t. P.iehce ~~'.d l~~anu~~c,~~c~ Alr~li~nP ('~ntch SIAt! d {MM .o~ w v ~ . . Iill(N (N wMA~ (fh?It~• Maf~MO ?N YI\ YA~M~O tu~~.w~a: SrtwriM m•~ ~ } teww., wU~Owln h~v{i~t to~v.r.,~ =.~ia~Ne'ce:vi • I«-~IlOl.6 ~ ~~CA ~N ~~lhhlP(1 1~~ C~IR1~~~11 1~Q({h(Crl ~~•w r M~~ SOCI~I SIC !M~ MUMk~ USilA1 OCCV?Atl(,W ~o•.~ ~~re +~a• r~..~ ew.w. r~~~ n• aM~ IM MK~IItt ~N MRKR/~I n((W4~ r ~Owrf. f`Ir Mn~~! ~ „ 33~-32-0962 Prtnt3 lrla?ta~ r~ Cn~i ht (i~~o . «.o. ~s .l ~ •e..oor MS~OI?Kl~-SU?t COVq/t OIt.tOww CNIIV~IHW »~~r~....~~_o~ vq~~ ~~M ~„u..p1 t Flon.i~in Ct. Lucie P~.at ~t. L~i~ic ti''+~S ~52 ('~~tt.iti St. •t~l~ -H~W ~~n~ .y~a~ ~•n a.~.hN• wR~hr.~~W •v .~wer~ uv DonaCd Tom~+.~o~r ~ kallrra~?re 1?rOW~NI-_ Y~\~IC, ~M~fllt .v~~~~ w ..'v v.M. fr• 4 Ska/ion 7omE~bon 3~? t'r,~ti~ c{.~ i'c~rt ~Ct. lt~~io~ ff. ;~t.~ . ~ut i ot~lN w~s t~uslo ~T ~~,N -:r.r..' r:~-~rsr.: " _ ~tNr1~ c~w. <.•r ~•uct n~ ~.w r.+ ~..1 t?~ ~ . ~~•.~w n..w~ •w w.+~ ~ --------~i1fl:vil _ - ~ t~ NI . .l . ial----"-'-~- - " - - - ~ - tOraorOr~i H ~~n ` ~ - ~ - - ~ - - A ' .~~t¦ uw ~ I (~1 Or~i ,p t~ ..uN.n u~i~ { w"ii'e. ~i . w~.K~ o~ u..,r~ ~.~~a i ~oN t~1rN ~~1~ ~ Q kl - - ~A~t ¦ OtMl~ S~ONMK~Wi CONDrtqHS ~o-.wwan to..H~m«.: ~n w.... ...~r ~~u.~~ ~.u~~ ...n.. . e ~~ViM~• M •15 .ru . ,..ns ~w !1N M l: ~N~1~• ~~~~~~^v.u~1 I~Y{~ - - ! - ~ e~ er... ~ ~ ~ - ~ i7~i-i.o.~~: i+:, :i.i ~ ~i~i _ _ _ j,A ~ ~ ~q - - - - ~~~~M~~~ ?If1W IN~(J~\ I\IC~I~~~(1 • f~M1 r~ry~ M IMWI~ ?11t 1 M~~If r~ M~~ ~ ' M _ 1~' M ~ ~ lM~I~Y A1 ~MO~R u~ow~. L~P, ~~[xfi~ IMINIQ~I anqr o~ e w.~ O~ ~o.r V~N ~ ~MK~n qf M r0~ O~K~ rN.~R ~tN[~n~ . ~ M~ ~II ly CI~1rK~I~~- rOM~M M~ HM br~ N~ •y u~~ L~ w~~w~ ~~rN Or ~ Mf1~+M ~y~ ~M p~~~M O~(VM M hM~ T, M MtfKU»~ . .w~. s.. ww ..w~ a.w~ ~ .m.~n ro ~ ~ .w 1n M N1~ }~f N[f~N~ ~Wr 3 I~ 1 ~ x ~ ~ d r~ ~.n~~~OM. N~ ( , / / - . 7VT ,1._ _ 1 ~ _ ~ 7~ - il.~ o Y .o w» ..vw,n n.a. -2. ' - - - .1~ 9 _ . t[RtrKA/lO~t-MEWCM~tAM~-~~' w M~.y~s M +~M M M~w~ rs• ~i<~a+. ..s •~o..~...~.e n.~ ~ ~ • It~Mw~~OM M~wf q~v ~M/p~ w~1 w~~fY~.~~Or. .r w o~w.~r. .n.... .r~~ «n~.~ N•w~ ottw~N b+ M~~S ~M NM a+~/ t.Wln~ Ya~• ~ l~ M f(~~/,(__.y"~ ~'_r~' M. _ Lt ' _ - . . _ ~ ITU~:f C 11 Il~~li~unt.9 1'~ • n• j Sif'.~~~1~N1 e~, n~ ~s 1~.~ 1f~~F~ SNJNh .~....w. rl. .~.i. f 1 '/s/~,`~ ~C ( ~ l\ MA[ . - - - ~ v„• M i~ - j _ ' ~ i~} 'Ti~ ~ ~V~ - `~~`~I~±~1'l~Slare I?v~nuP, F~r~ ~~{'~~rc•~, F. . ...~~i~lr(1 ~I/N111. CfE~t~. ~lrOvAl tf~~ M CqM~~M~ - •~aW " '~~.v .ei.yi . ~ . ~wt~n. - - • a,... , , g~,~ _ H<,Lecnebt Al~m. ~'~~tt. rt. 1'i~ycF Cfr~.ai~~n ~ oAi~ ...o.w+. . ru?iie~i Mo.? ~N.,.r um .,Y~R c~ , , . , w J(lJt 23 ~91a ` Sa,i.n~ F~u~c.ynf I~i~m~•, ~(ll~jl.~ l/(r~c~.,•~l'~, ~Si~~~~~, lP. ;31rn vs. ~18~z iu~_~ . oi swa:nri`r - - - ~1<asl~~ . .~tn.r~ ~ . r..q n.~~.rn ~.v.~ no tn.• ww.7/l6 ~ - f ~...1_~m~:~Cy .'.3~ i97R i;_ ~~w~oo~o ` . I hereby oeriify tfilt to be s true snd cprrect co~y of 1t~ I~x e~ ~ MtY flR. ' Re~l:trar'~ reccxd o~ file in fhe St. lucie County Heelth I~,art. ~~ER t0t7~IS~ ~ ` - R~n f ~t F ort Pierce, Flarida. L E~ K Ci R. U 1T C O I: RT - . ' ~ERIFlEO - (YV~r~ing: Not valid ~nlass raised seal oF the St. Luti~ - ~ Co~nty Nsal?h Depa?~ment ii aflixed.) JAY Z] 9 3s AN ~~C~ r~ , ~ ..`i~..~t ~ ~ ,6 ~ N. D. MIIIER, M. D. - - . >p•.w~s:. , , , i . . _ CouMy He~Uh O/Ficer d, ~ocet R~~~?~n, . ; } ' ~ ~ /,~f/ ` . _ ~ ~ 7 ~~f ~7 l ~.G „c«I G , ~i' rGc ~•L : O~putY loCa) Rerr-+•+r . • . . . , !-!~rrld H. ~sOldrtWn . TTORNEY-AT-UW :?'e5 Mcmirq:ide Blvd. ~ St. Luci~, FW. 33452 eornc ~ v~c ~ . . - - n_~.:;~