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GERTIFICA'~'E OF DEATH s~.~. xo
eratx xo, fAiliUa Diat. Ne. ~ Cwtodian's Na
1. NAME OF ( s1) lMiddii) l 1) Z. DA~E /MwW lD~=j ~ar)
DECEASED ~ OP ~
~r,P. ~ p,1en Aurlaey %~(lvc~t A'cAf
ee ~ ~ a~n~ Gc.~v6eie 22
3. PW1C~~D oua1T) . D u~ d~cw~d iastilu4a~t rNid~ac~ Lslsr: a~a1aaio~)
L~I~.tVIl + Stat~ ~eV/[t2~Q Ce~ !
~Citj et ow~ Io Cil7 Lini~~ LEliGTH OF ~a itT limib LE!lCTH OF
tV~Q~e Yq Q Ne Q I 8IAY ~io this plae~l To~er (~R~ f-~ Ta 0 21e Q SiAY lv thi~ p1~c~)
_ O- ~
N~2iosp. W Iastilulioa LENGiH f S&ri~t Addnu or B.F.D, aad Do:
No. •
Cla ~vn ~je~e~ral Noe i~ul I $~A ~ `
S. SEX i. 11AC6 . D18 LA E!Sl+N w lor~iqa touatry)' 1 llEN OF ~T IS. 1S NESID ~ D~`
cou ra~ a~ovN.
Fe I~ue. ! Y'ertne ltntR' I ~I.S.R. _ Y»o ~ caaaxnor o Oc~ofi~t c~5,/~'f.~
DA7E OF D1ll7H I9. AG~IIe 7~+~) ~ UNDQ 1 YEAR IF' UNDER 1~ H83. IiJ1idE OP CEItEiEHY LOC/1TfON (Cit* or lews) (Couat~) (Sta1~)
las! daT I{aatha D~~s liow~ Nia.
~ul~ I9/~I ~ ~ ~ ( ~ Fv~ee# LvuR r Y~ nn
l~ IIMI(H IED l1EVFJl ;1ARplED Q II liaaiW ot Widow~d Gi~~ N~ ol Spou~a 17. ENBALMEB"S~(
GNA~~ j(p.
WIDOWED~DIVORCEDp ( . /JJ~,~!/' 1• I I~~
3EP]lAAreu ? Natitv A'cA~ee ~{ts~ ~ ~ K,~=
11. USUII~OCCUPATION (Gi~~ kind of wo?k ~LIND OP E S[NFSS OA If. 08T1Cl11N >
don~ dur}py moat ot werkiuq lil~. ~~~a il ~~ti~~d11NDUSiflY
JeQChe~ I~ „ Y'oae D~cjieon 8 Sva Funeiru~l Di~ec,~vire
p~~ e ru
12. WAS DECEASED EYCR IN U. S. ARtYIED FOHCFS? SOCIAI SECUHITY NO. 19, 1~8C-!AN'S ADDAFSS
(Y~~. no. or uakaov~a (U Y~s. Qi~~ wai o~ d~t~s o1 s~r~ic~)
nv ~ /6~ A. ~~nvug~i S#., r.eebvirv, ~~~a
i~: Fwn~a•s N~ - so, u+eoa~+xr a.w~~? .
_L~u -~v~lvc~t A+~• /~cur~ lf'rA~ee Nue6anal
1~. MO~'3 MAIDEN NAIAE 2l. INFOMtANT~ADD6FSS
~an,~y S~t~.e6y 3~7 f~titlowl~ea~ QL ! %~.~6oitv. ~Q.
[2. CAUSE OP DEATH [Enut onlY oa~ c~us~ p~r lia~ ler (a). (S). and (c).) FLEASF~PAINT •1H A AL ETW ~HO~ WRITE P C
ONSET l1ND DEATH l. (
PAM L DEATK WAS CAUSEQ HY: ~f-.
1MMEDIAiE CAUSE /~(?t ~M~ A ~ / ~ r I ~ ~ ~q /
Z
~ Conditiea~. il isT. DUE TO (b) ~l M'~ t r'~. 1 O `')r.~~• ( I ~
O which Qa~~ riN lo -~T
F: abo~• caW~ S• I~
t s!ahaq Ihs und~~- ~
V lyinq causa last. DUE TO (tl
^ . _
PART U. Oth~~ siqw6canl ccad~tion~ contnDutioy lo d~~t6 bu! eo! ~~l~qd 10 ~h~ t~~minal disw~ condition 9i~~n in II~rt t t~, i 2~. A1ITOPSY?
N I
G
W YMQ Ne?
v 21. ACCIDEN! p PLACE OF INjURY (~.q.. in o~ aboul tNtURY OCCURAE^
v SUIClDE []~homs. 1arm. ladocY. str~~t. ~ Whil~ at Wo~t 1 S r~b~ c~rtif! lhat I a~l~nd~d tL~ d~c~as~d Iro~ ~ _
HOMICIDE ? oltic~ bld4•. ~te.) -Not W6ib at Wo:k f7 19 7- - to 19 ~ 3 that t last ww 11e dse~~ud
W (CITY OR lOWI~!) (COUNlY) (STATE) t TIME (Montb) (DaY) (Y~u) (Nou.; ~1 (~VI' 197~ . ~ad /Lat
E Of ali~~ on
I INJURY d~ath xcurr~d at
~m., irom Ih~ eaus~s and on lb~ da1~ atai~d aeo~~.
IiOW DID INJUAY OCCUA? 26. S1GNA7UHE ~pr~~
oi
TiU~
. lL n
27. UAiE RECD BY LOCAL ~28~ GISTBA~'S SIGN TUA ADD DATE SIGt~D
REG. i L .1 IL (
!r - / ~ _~!1: L_1 /~u t t; ! ti 1 w~, ~ °
:~t~~t 5 3(12-I-56) ~ ~orqw epaAmea~ o c • t
. Vital Records $erric•
i
State of Ge~rgia
County of CLAYTON
I hereby certify ~hat tne foregoin~ is a true and correct abstract
~of the facts of death as shoWn on a permanent record of death on
~
~~~~~'3.~ this oIfice.
~~'t` ` ~ . , ; ~ .
`.,~;ti~
.
' . _ . . '-i_~ Signed
, ~ .
~ ~ - j , ~ ~ r' ~ ~ust ' =an of Vital Statistics Records
r ~
; ' : Ij ,
;~-~5$AI, Date Issued_~~-~~
~ -
, . ~ _ i
j?
ADM= 5 /.~,'T~ ~ .
FILED RND RECO~Ut~ ~
ST. LUCIE COUNTY FU
P.~~C~R ? O~TR~S -
~ ~•K ~i~CU1T COU~~, .
. ~ 'r, •~?~;ED .
~CT ~ 8 IO 36 ~M ~ R
tocx i~~ f ~cf s43
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