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This Death Certificate should be referenced to the following
described property:
Lot 1, Block 1~ REPLAT OF PALM GARDENS, as pet
plat thereof on file in Plat Book 12, Page 42,
of the Public Records of St. Lucie County,Florida.
WARNING: It is illegal to duplicate this copy by photostat or photograph.
3:•~ ~ , r~~ ~ ~ V \
Date No.
This is to certjfy that this is a true .copy of the record which is on file in the Pennsylvania
Deputment o~ Health. in :ccordance with Act 66, P. L. 304, approved by the General
June 29. 1953.
. . ~
(Fee for this certificate, t2.00~ Leonud Bachman, M.D. ,
' _ . ~ Seccetuy of Healeh
~ Harrisburg, Pennsylvania
~il ~ "~!OIU-300II-1•~l ~`-~0 COMMONWEALTH OF PENNSYLVANIA ~(3
~ DEPARTMENT OF HEAITH Fih Nw
Primary ~O BUREAU OF V1TAL STATISTICS
o~~~. ._.._______~~5... CERTIFICATE OF DEATH R'°~`t"`"
PLACE OF OE/1TH I 2. USUAL RESIOENCE (VUbrrc draw~ed lired. It i~stitotioa: reodeace
COUNTY ~ ` ~ t STATE UN1Y ore admi~iao).
L-Ar C~°~-~ 1 ~h~ ~~t~Cl~S-r~~2
b. CITY (If ail?ide avr~~rate limit~, w-rite RCR3[. e. LENGTH OF m CITY Qf aubidt corp.qte limilr, srile RURAL and 6ire LoaeaAip)
OR a~Nl Ki~'c IownaAip) STAY n this OR .
(30ROUGN ~~e Q. ~ T- I w~«~ ~,y soROUC~ l- t~/
~'_~S T"--~~ ~
d. FULI. NAME OF (1f ~wt in Mn~.ital w imtitution, ~ire stnet ad- d. STREET rural, ~ire loe~tion)
' HOSPITAL OR ~dr~e~s ~or~
~lo~cation) ADORESS Q~
~ - _ ~HSTITUTION t~1 ~ RL~~-__ .LZl.L_c2111A ' ~ O•~ • ~ ~ ~ • ~ ' ~
; . ~ LZl t c2
f 3. NAME OF (Fint) L b- f?/1i~i'.~ltel c. (1.ast) 4. DOF (YonW) (D~1) (Yb+) .
DECEASEO (1~ C h t I I~ I DEATH J V
, ~ ~~e ~ ~R~, J4 w~ t s .
~ ;EX 6. COLOR O FiACE 7. MARRIEO, NEVER MARRIEO, S. DATE OF BIRT 9. AGE (Ie je~n 11 uwkr 1 yw N r~r 24 hn.
E WIpOWEb, OIVORCEO ~ birt~T) Kuot3s) Dafs Haan Ytn.
€ I /'Y (S~.cit.)M~-~2/~t~ -.ZS-~9o~ I nS~ I I
~ USUAL OCCUPATION (Gice kind 10l. KINO OF BUSINESS OR 11. BIRTHPLACE (Alao 6ise SU4 ot ferriao 12. CITIZEN OF WHAT
6 ~~,r; d~.ne durirry~ nast of r-orlcin~ ~NOUSTRY ~„~L~~y~ ~wri o
~ . r~rn it rrtired c Q ~ ~u~Rs•C7 •
F A7HER' NAME 14. MOTHER'S MAIDEN NAME
~ __,i4 „ g F A~- ~j-. S[* L~,111t R F T' T~ ? E ST -
~ ii'AS OECEASED EvER IN U. S. ARMED FORCES? 16. SOCIAL SECURITY 17. INFORIWINT'S OWN SI(1NATURE ADDRESS
t uniro~sn) (ll cvrnplrtt idt NO• . /a38 (J r. c5~
~ I d ~wtiAcafe) ~ ' ~
~ C:.USE OF OEATH _ MEOICJI~CERT~FICATION ' INTERVALBETM/EEN
-~:r aw cauu 1. O~SEASE OR CONDITION / ~ OMSET AND OEATH
~ - S~~r (a), (D), OIRECTLY LEAOIHG TO OEATH~ (a) l"IZ!~~ ~ ' l7~/~~
. ~ ,i'i- ) ~
~ ~ ~~~5 ~oei ~qt ANTECEDENT CAUSES DUE TO (b)
~ the modt o1 ' !
/Jorbid cosditious, i/ anv. o~sinp rise
q - Jvysuch !o ths abou~ eatist (a) rtatinq ths
It mea+u tht ewderl/u~nfJ cau.se last_ DUE TQ (e)
=::c, injvry, or OTHER SIGNIFICANT CONOITIONS
,aii~ction whieA
3 ~•-i death. Cawditiona eontr~butinp to t)~e drath but not
relatad to the disense or condition emruino d~nth.
{ :~:a. DATE OF OP- 19D. MAJOR FINOINGS OF OPERATION 20. AUTOPSY?
ENATION I - I YES ~ NO ~
,E a dCCiDENT (Sprctiy) I 21b. PLACE OF INJURY (e.~., in orI 21a (CI7Y, TOWN ANO TOWNSHIP) (COUNTY) (STATE) '
SUICIDE al..ut li~rrn~, Lnn, f~rforr, strret,
; r~6Y1GpE oM~~ 61dg.. ~tc.) t
T:+NE ~~I..nth) IUay) tl'nr) (Iluur) 21e. IHJURY OCCURREO 21/. HOW DIO INJURY OCCURl j j~_ ~ 2~ }~+~t•E
0~ WRileat NotWhile
~N~URY m. E.ST.I yyork ~¦t Work U
3 _ _ _ - ~
~ _ -
$ ( hcnbX ~ilY that I attend~d the decensed Jro~n .l.Z -.L. 19.~ W .~l 19,~~that / iast mte tl?e deee~a~c+d ~
clere ow 19-.~ ~ and tF.at death oce~erred t.o~: ...~m, SS.T.. /ro~n tht ea~es awd o+a the date +fated abovt.
23~. SiGHATURE ! ' .D. ~i oll~~r I 23L.'ADORESS ?Je. DATE SI(iNEO '
~ ~ ~ ~.~i~L~~ ~ I / - / J
~ + B U R i A l. CRE 21b. TE 21c. NAM~EMETERY OR CREMATORY 24d. LOCATION (Tosn, t ahip
and [aunl~) (S4t!)
~v~`1HEM.OVAL (5y.cif~) ~S2 ~s[11 ~ L,l~ ~cas-rEAft[11~. ~A
I~ .l
' T F REC'O BY LOCAI RE61 R'S SIGNA7U 25. SIGNA7UR OF F ERAL DIRECTOR L AODREiL `
S ~2~2 3 - /9 s.3 ~ - - ' ~ l~" - - ,L' ~~1 a ~ •
~ - ~
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~ ~ .~F .`ry K ~.i ~ . _ -~r---~ =-r~ t