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Palm Beach Cou~~t Healtli De - artment •
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st~tl• of FtuTida CERTIFICATE OF DEATH
lkpattment of Health and Itehabililative Services trwTt FIL[t No.
VtTA[r STATIS't'IGS F L O A I D !l -
Rt61L1RAR~f NO '
TYPE OR PEi1NT OEClwSEO-NAME If1• r.lelf rest SE>< pwtE p OEATN 1 rorr¦, e••, •e•¦t
'N t _ TEDDY JOHN ROOSEVELT TAYLOR :Male , t
VERMANENT
BLACK INK RACE rwlq, wlGq. •w/¦IUIa Ir•eu.•, AGE r•fr YI•et¦
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q.. wq1• r e.. CAIE Of W1N r.Orrr, N•,
CCwNtr d oEAtN
Nc rfrler•r Ufrwe•• Irfufl rOf N•f uW¦f ~ f1..1 f
_ White k 6 ~ L S< ~ ~ Ma 16 1 14 Pa 1 m Beach
O ~ O CIT11, /OWN. OR IOCAIIpN
pI OfA1M -IrsIN cw. ¦e.Irf IgSMA1 OR O1f1E~
NSfItUT1pN-N IM wOr Ir UrM¦. 4M fIMIt •M r.w¦f¦ 1
frltr• •ff M rq
>s West Palm Beach it Y_es f. _ _Good__Samari t_an Hospital
STALE d NRM .r wor I« Y f ~•+1 CITIIEN.O/ WHAT COUNTRY MARRIED. NEVEi swtl1EO. SURVIVNG SPOUSE Ir w1, c.w r•Ie1M wrf r
_ coe«..•t w100WED. DIVORCEOIfrlcr.l 1
.tV.,.fflelrrtf . North Carolina ~ U. S. A. to t+_ Blanche E. Anderson
1.•ro N a•M SOCI~I SEC'1Mir NUMRE! VSUM OCCWATtON Iw.e ¦.re p rr0¦a eorf Owlwo roft p It~q
p1 wSwfSS OR tNpllSnr
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N ;:f t: 224-18-5405___ I,i Mechanic ue C i v i 1 Service
•6WffK111 ~ES1DE?Kt-STALE CONNTT CITt, TOWN, OR IOCAT1pN r~fwi
cIr• rrrm STREE) AND NUMEd!
rtrytM• •f1 O¦ MO '
La Florida lee St. Lucie 1•t. PorX St. Lucie t•o Yes Iw. 6 7_ S. E. Calmoso Drive
fATf1ER~NAiYE nyf r»eaf UQ MOTHER-Af/r10EN NAME raft .recce oft
rt Dol has Martin r Ta for IF I sado Brooks
INfORAUNT-NAAIf HARING ADORE SS ur¦uf W ¦ r e r•p • cm p'w.r.., fr•n, tar
I)e Blanche Anderson Ta for r,n697 S.E. CalmOSO Drive Port St.Lucie F1. 33452
?A!f t. OEAM WAS CAUSED 1T. (ENTER ONIt ONE CAUSE IEf 11NE /OR hl: 1?L AND Etp ~ ~ • fr"~ r"
NIVINr Or11t •rle N•
tR- rwwn c•vfe
• E.T Res irator insufficienc 3 weeks
co«nrlows, r. •w•,
rwrtw e..1 .If1 to to C~ionac~hsts t n .,ear 8
rrrlN•n c•Yff ror, ,w p ~f • COrf1011trK1 pl ~7.•
funwe rwl Yr•ei¦-
1.Ire C•Yfe left - ,
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BART M. Ot?IER SK.NIfKANT CONDITIONS- co•.a•worn cowr¦1¦Yw.re to et•tr ¦w rqf pone .o c•Yfe 4r•fw ror r rer wUTO13r fT rES wre¦1 .Iwerraf co
r ns p 1•or MN¦fe rr Nu¦r1«wo 41r
p ee•rw
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1?~.M1/t1 ACCMENT, SUKtpE OR AT~NJI~! T rre~tw, M.,.f•er MOW INJURZ' OCCURRED I Irn¦.wrWt p rww¦• rw /ut r p¦.Vt w. per t{1
1 , OR flfOEtERMwED
- 7M 7t?o 7M1)t M ?Or! -
INJURT AT WORK ?IACE Oi NlI1RY •r IIQrf, r•w, u¦tar, r•eo¦•, IOCADON r A¦eff M ¦ r.e. rp-, an m fo¦n+, sun r -
Iff1C1/• •ef O¦rgr OMKf ¦re6,fK. IfrNw•f '
' 711• 7M. 70Q
CERTNKw1K1N- rortw s•• nu •rorwr e•• nu •rre r•fr f.. «r.i111e •N.f Or . w/oa I.or •Mlr w OEAM OCCYMEO a «II rVtf, o. «It
ew~fKuN~ - t0 - •ro1•rw u• a.¦ ¦ae• •nn paw. Lwow. e•n. •..e, ro r•r N'
r •ntwof0 twe o w -w -~Q ~t p p r• ¦MpnlfeG. O !
7++ olc••uer¦o1. _ ~ I-ZS-fig 71p~_ 2 'S V 4~4w70 :,a Did not ?1 M +otw/cwferfr{rn !
i CEl/MKATION-MEDKAI EIAMYVEf CM CORONER ON rwf f.flf p rrrt wOY¦ p p•M tw1 eltfwwr .y f¦OrrOVrK¦e N•e
- 1¦•arr•r10.. p r1y 100• •we/p¦ rq r.r•IIrrG•r1er, I« r• p..1o•., rOw•r N• •f•¦ r10w '
of?rw OC(Vf¦f0 01• w11 O•rf •«e OY! p rlrf 4Yflrf/ fr•rfe ;
77a _ _ M 27p
CERt1i1ER-NAME mrf o. corn ~ - 51GNAT ~
oreNl p r.nt DATE SIGrtEO rro.Irw, e...eur
Tsche~ S._ Fen$, M.D. r7~e ~ 7x A ri 1
Mwa1NG ADOeESS --tfRtpl(e s::.r.-c::
•
o'... i1n w.... sr.n to
Ii45 sarrrr SIT. 7M 2
oar '97,- IR? BURIAL, CREMATK)N, REMOVAL EAfETERT OR CREMATCJ<r-NAME (OCATION crn p ro+.. ,r•rt
:~¦t¦! OoCVS rtMCrnr
7•• Removal :.e Mount. Lawn- Cemete_r - :a North- Wilkesboro North Carol i
- Y - - - - - - - - -L _ - - ;
DATE , ro.1•w, o••. •1.~1 tUNfe•t rt0¦¦(- rJ•Mf uttl,At?pefSS ~ fnrlr o. ¦ / o «o . ur• oe ro.lw, f~•n, nr 1 =
7«t A r_i l_S __1 a.Quattlebaum-Holleman-Burse 1201 S.OI ive W. Palm Beach,F1 .33401
iUyEfAf ECTOR-~G?i UM ~ R[GtS R-SIG7rtAt oAr1 nc11r1o coca flC rsr¦•¦
I
I I HEREBY CERTIFY THE ABOVE TO BE A TRUE AND CORRECT
j ~ , ' ` ~ ~ COPY OF THE REGISTRAR'S RECORD ON FILE IN THIS OFFICE 1
` (Not valid unless the seal of the Palm Beach County
~ ~ Health Department is affixed) -
....E
~ • ` ~ C.L. Brumback, M. D.
I f¢~F '.y ~ ` ~ Apri 1 28, 1978 ~ Local Registrar - -
- - - , Bureau of Vital Statistics
SEAL Nest Palm Beach, Florida
'~9 su F~f ~ : 36
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