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HomeMy WebLinkAbout0461 ~y~198 CERTIFICAI"E? U1= DEATH wr~~t r~~~ ?+o - FLOAIDA - - - - - - ~ ~i e~n~?~ No,_- - - - - _ nr.:ia~n~?n • - - - - - - . _ / . 1. pLACE Of DEATH ~cooe Ho. U5UAl, R[:91[~ENCg ~ww..s-.,..~u.~t ui..u~wM, •.•~+......r-.. couw~r s~niE cou?+n ~1~~MIM1. ~ s_~._.Ll~cae~----- - ~`~'-t2 _ I~.Lot-t'f:`------- ~t. L•~cie r. Clir Ilf w1iFN e~}r~b 1~~4~, •rlu KORAI.1 c. 1fN61N Oi ^ t. CIIY tlf wddM ta1~+N 11~11a, ~AU Rt~it~l.i ~ ot srAr w..w., ot .g iOWN ? p~ Z~' T.,=~ _ TOWN t,• I'i_~~ 1'C~` I• I~l.- - - - - ~~[a_.l~~'L~'c~_--__----- - _ ~ y - A. Wll N~uE Oi lu..~ a re.~~w w IM~IIM1~1~ ~~1~ ~(fwi ~+}!Mt M Yf~ilMl d. St?rFt ~ nr ~..i, ~~n M.ne.r HOS/I IAl Ol APUIFSS ~ _ ~NSnn,n~~~ _p~erce=Lemnrial _l~o:;~~.._~,--, . ~ _ - - 1~~~?9 t.~Cn2•r~ ~ ~,v~~~~i~• A ~ 'DEC A EO (11?d) _ IMlddkl e. II.a.11 1. ~TE IMonth? (D~tl il~~+rl - ~ ITtD~~?1'.twe SB~,.+~+{~~ Tj - '.~'hnnii;nll----- DEAtH---nCt,'-,-~.~~ _ ~ ~ t. SEX COlO! O ~ ~ ACE 1. MAItRIF.D, HEVER IAA~~IEO, ~ pAiE O~ tItIN 1. AGE ~t. ~ ~N 1~ f~~r• , Ir .~f~~ I~ WIDOWt~, DIVOtCfO ~Nwur~ 4Y tlptd~rl ~~.nur t+.n~n•_.. ~ _ya1~ ,rtLte _ _~~tcrr3.<d . ~'•,r. 3, -.li"-tc'- - ~'1-- - - - ~ ~ ~ ~h. USUAI OCGU~AiIOH~m.~ t~rf ~t .~r~ IOb. XIHD O~ •USILlFSS Ot 1?b 11. eIRtIRIACE ~nt.~~ ,r w,~a. a~,•n~ I}. C1tITiH Oi WIMT w. w.e...~.~.«aw ~u., u.«i.«u ousi~r orue+uT ~ c~ ' __.~4mmcrcio.L---- - -x:~i.t ?,~,1.~;.~. c~,. U. A. . '7. 1!. iA1HEl'S NAMi 1~. MOIHER'S AIAIUEN NA/.IF ~ P . , ~ s_Thom~sn~ !:i:.: oqri~KickliiliL~r ~ _ _ ~ IS. WAS CECEIISEO El IN U. S.ARMEO i0 CES1 It. SOCMI SECUl11T U. IUts~RMAHt"S SH.t1AtURE t Il+~r.rMrwl n~sr.d~~r~rwa«n~~ NO. _ f~nr:l 'l~l~~~~~~~~::•it~ a I AODR(ti Goer~~i-7?v~•,>>»~, 1~ f.. f`i.- r~:~~ - t--_~~` O r 1~. CAUSE OF DEA~Ft MEOICAL CGRTIFICATION IIMf(11v~~. ~~~N~~M W~ L~ter aab ~ eawr OISEASi OR CONOIiION oM~~r ~NO ac~~N ~w pp fsr f~T. OIRECiIY IEADIN6 TO DEA111•~~~~~o,~~on1r_;,t__.thronl,u~Ls - - - - - - - ~rn~Kr ci?usEs ~ ~ •r~w+.....e ouE To tb1 - - u~ .~1. 1Mty. Y..~fJ .~.wliti.w~. i/ a.r. ~1r+w~ w~d ~~esH /~il~n. rir b 1~~ ~M« er~s f~i M~t- ~ utA?wN. ~te_ /t sw~ iw~ W ~w/ni~i~/ arw I~~t . l~~ ~irti~, h/~ry. ~r DUE i0 ~c) ~ avnr&.r~iew r A t~ O1HE~ S16NIi1CANi CONbIl10H5 ^ ~ ~ ~f~' C~w/ttiwa hwt~i6rtiw~ N fAr ~irN1 6r1 wet ~ reLfe~1 fs tki rir.w ~r MR~Iilinri MYRi1~~ ~IMIA_ ' ~ Ib. DATE OF 01E1A• IM. 4AJ0! FINGIN6S OF O?ERAiION ' ~ 7r. AUtorsri ~ ~ . _ C~ ,.o E~x ~ Ih~Mlbl . I~~cIt~1 lib. /LACE OF fiIJURY ta~_, G w~wn! llc. (CIT1f Ol iOWN ~COVNIr) (STAtE) ~ ~ l1~. Aeuo[w~ r... r.~. r..~+s. u..w..w ~~da ..te.l l~ r.al. ~t.b Et•~W.? _ •UICIOi __UQNIGl ~II. i1ME IY~1 IDV1 IT~r~ IN~aw~ 11~. INJU~Y OCCURlED O ~ ~ iMJUl~ ~w~u?r ~orsant - - . ~ .e.. o ..,o.. a ~ t!. 1 he~eby ee?(iJy Ihal I oflrnd~d Iht d~t~atcd Jmm _IZ~2__. Ia~~.., (o a-2,11_, to ~l. lhnl l la~t ~n~e Ih~ d«~a~~.7 nlifv~ nn 1 !A nnd f/~nf diafh o~rt~rrrd ~l ~~O. rn. ~nm fhr ~m+.ut ond nn !h~ da(. a/~f~d ni~~~Y. ~ ~ 71~. $1(3NATURE - - - --ID~•K or U~M? ~11b. DORESS - - )ic. DAIEtIBNFD 2i ll ~~1.Qj'{r~'i ~J~-tl_~•1 Na. ~ U R 1 A L, C~EMA- N!. OATE 2k. NAMF Oi CEME/EtY OR CQEIJAlOR1 ?ad. LdCA*!ON ~tyy, fo+n, or roho1~) /St~i.l iION, REMO~AL ~~ft~? ' oY~__ ~~_~8-'~?~----~--- . . - _--[;lc~nnvill~, ~ DAtE REC'0 ~T IOCAI RE61S1UIR'S S16NA7U~E TS, tUNERAI OIIIECTOII'S S16NA~URE ADD~ESS ~E6. - - 1 ta T~chards~n ~i . r. , ~ 11. _n_~. i'.~i r~l - - - I' t.. t-i- ~r^ 1 hsrebr oertify ffilt to be s true and carrect copy of the lrx~a? j= . Regiahsr's ~ecard on file in the St. Lucie County Health Dnpart- . m~nt at Fo~t Pieres. Fb?ida. _ ' s (Waming: Not vaiid unless reised sea! oF the St. lvcl~ ' r` - ~ Gounty Health Departmen~ i• affixed.) ,r t . ~ - . . • ' N. D. MILLER, M. D. . a~i~t Countr alth Officer d~ local Recj~~s: ar t` t.. :t t . ~ ~ fG~/J~ ~ . ~ ~ _ ~ , . ~ ~ a» ~Y LOtal Reoic+.+~ t FILEO AND RECOROED ST.lt1CIF COUMTY FlA ' ROCER POIiRAS ~~FtK ~tRCUiT CCU? ~~:ft~ ~ ~ ao~K28i ~acE 4~ ~ ,)ru 30 2 n2 PM'Z8 :~:~2198