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l CERTIFICATE OF DEATH
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iT7E, OR ~RINI IN u1MeM~~°aTM° REGIE:TRAR•a NO.
~[QMAF:ENT INK DECEASED-NAME rust _ .wou - EAai SER OA7E Oi pEAM I ao«iw, Nt, n•l I
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RACE rwrl, «l4ao. •W.K••I INaI•n, AGE-l•ir .wu I +s•t i ~..~te : o.. DATE 01 RIIM t.ONrM. a?.. eOUNn Oi DEATH
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u.s:.e <,n lr.n i nOShTwt OR OTHER reSTRUTgN- Iw pot w uara, 4m srrl: •r.D l•wsa l `
CtT11, TOWN. OR LOCATION O/ DEATH • arlc.r• ns of No 1 _ _ -
7? - 171 ~ ;
STATE OF RIRM 1 Y «Ot M r. s. N...l'Gi1ZtN CF WhAT COUNTRY iMARw:£O, NEVEt MAiiAiE O, StIRVNRiCr SPOUSE tr r,H, Or+t rap« .t•tq+ ,
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.fw/q oece.seo SdCt/btt NtIWEI US.rAI OCCUVAT~r+ ~ a.n awa w roaa oa.e Twplrw Wyr w KWD OF MFSWESS O! YdDUSiRr -
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ol.lss.o«. RESWENCE-SiAiE COUNTV CITt, TOwN, Ot IOCAi1GN wsa.l cm .rswa STREEt ANO NUMIER _ i
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~r-s_ iATlsft-NAME flat «IDOIt uar MOTHER-,a1t1OfN NAME fi[r rOa[ _ usr
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INFORMANT-NAME ;MwA1.•.L AD:.RESS lsiglr a a-._a...o. cm a ar«, seta, E1?f
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?AFIT 1.• 1 DEwM WAS CAUSE 1 •rraoa.r•n ~ ar•1
/ 'iN:f4 Or::Y ONE CAUSE ?ER lWE FOR (o). (al• AND W, aerrteN o«xi •Na ef.rw
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ro c•+rr 4.,[N Iui 1 al AUTO?SY u •fS ref[ [,«o,«4s c4«-
' ?ART Y OTHER SIGNY T ifC/: - co«a.no«s~C.rf+-. ~,..c ro at.r.. air ~.f 1.[s a «o, , s.alna l« wrl•..r..«4 c.~s.
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~ 1 7.eeappii~~l ACCIDENT, Sin:WE OR DA WJi!!Y t.o«t«, o.r, •t•.r HOUd ./?tpW INIURY OCCURRED +1~~ wirq 1«r.n 1« r.[r 1 w r r u, Is[r rtl `
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INJURY At wORK RACE OF WAiRY •r «O«t• srgtr, f.ct x•, IOCwT10N I snln ~ ~a.f-a. rfD., cln M rOr.«. st•n .
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CERi+F:CATtON- wOwiw M• re•a ,.~..m D•• ' •rlD uit yr rl,r/INa M,.e O« . O10/o.b..Dr vyr ale OE•T« QCCUtiED •T ewe r.•Cf, O+ :r[
IY1SK1.•N: TO t .O«T« Wt RY a0a. •Iila w•rM IwO~i. O.TI. •..a. '•O 'w .t 1'
f mt«ato rife / Q ~ 71F `j 71. M f0 Mf 4'.rsfrl, et•t!a
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CER:rt:GT:ON-MfD~ E EXAMINER OR CORONER. o« r.l t.s.s a ewe .lo,ra or u•'.1 nu oacea.a r no«ou..ceo ae.o
e t•~,«•t0« d a,! aoor •Iq/Of tlrl INr lsT14•i1C«. w rr prw.G'•• I y O•• 17./¦•~ w0+f
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MA47JC rF1fR sr[ut o[ •.r.o «o. / - s~j~ -/~yy
itiEIIAE, CRfMATIDN, REMOVAL CUaE:e~Y 02 C.uvATOaY-N.tNi Y S• ~IOCATION un w ro.... sr.n ~
1 spur[ r
7e, Burial :,.Pine Grove ;emetery Fort Pierce, Florida 33 _~C
'.t: ~ DwTE f •OI•tw, s••, nu I ' WNEiAI HOME-nLwF wr[7 wil~.ifSS 1 uuet W a.r.o 1+0., em W torw, sun, rlr t -
• ~ ibibf~1~97~ 7f/ Lee-Peer 1'lortuar Fort Pi~'ce, Florida 3~t:~n
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~ ~ • ~ ?cG."' ~-S~Gr1AiJRf ~ DAtE IECEIVED aY Eow lEClstur
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' Rfer. 14TG 7Sa l_
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~ h:.:;;;,y r;:Tiilj/ this to b, a true and +M :;~t wry c` ;::s Lr:EI
Reg:s~rars record on fife in the St. Lucb Courry H;,;.i,:z C:,;rsr2~ ,
merit at Fort Pierce, Florida ti
(Warning: Not vaNd unless raised :ea) cf t}:3 St. Le;c:~ ~ -
Counry Health Department is aifixa~.) • •
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1 N. D. MILLER, M. D. ~ ~ - -
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~ County Health O;fic~: & Lcca! ?::~3 l - -
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Day Local ~gistroT - ~
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