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• stun of FtoTidu CERTIFICATE OR DEATH / ~ •
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VITAL 8TAT1sT1C8 IlaalsTpAlT•s No.
•nt1 Nleelt DATE DEA/M ~ rower, e•r, x•e 1
'YPE OIR PE11NT EA~D- 1!'1~Aat3
1 Pogue ,.Male ,Jan. 4f 1978 ~
PERMANENT !
BLACK INK RACE •wM. «Nlq. •NteK•w 1«w«. AGE-?.{t wt• 1 { 1 . LATE Of MtTM 1No«rN. Ms. COIN~Tr A .
~~s,-rLN.tN.t mite w ~n ~ {Nov. 16 f 1912 Martin
lr~~, ¦Q~'-'~~i~~A~ wMM cM. UNIq NQSi1TAl C1R OIMEt IN wW w uM., GM f1«n •M wYW1{ 1
• N Stuart ~
yea { Martin Memorial Hospital_ _ _
STATE of tiIR1N Ir «pt w v.e.•.• «.w CITIiEN M111A1 C01MIR11 W1t~ItD.
t1EwEti
MARNE~. 3URVNtNG
SIOUSE
Iir
wr{. t?M r.ww wrt 1
taw+n r WDOWlO, DNOKED 1 tNCrt 1
• , Illinois _ . U_.S.A. _ _ ~~i~___ _ n Jeanne _G7caham
.+ut ette•tu SOCIAL SECilt+llif MNllt+t~ ~ USUAE OCCIN~T'~ON Io1x alwe a .roa w« e1w1.w •wsr w ~tticD Of NISII+ES3 OR n+DilSTt1?
,x.10 N el•rN •rOeeNp Wt• Mw N MaeN 1
a~~•w J W Moon Distributing Co.
?I:IYr,o.1. oM „ 35G-03-4268 Ia Accountant u. -
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. e.:11wlw RESIDENCE-S/Ali ~ CCN1NTr CtTr, TOWN, OR LOCATION
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,w Florida IR, St. Lucie ,a Port St. Lucie. to Ye$ w 2441 TallKOOd Lane
fAT18R-NAME tact rN0?I t•« RIOTMER--MAb[N NAME rlesr r"~t w'~ 1
II Ralph Pogue N. Bernice We1Ch
IfMOWANT- MA~ttJ6 ADDRESS Iswn oe Rt.e. «o • cm tM ro•rw, n•a• tr1
„j~Irs. Jeanne Pogue /1041 Tatltirood Lane. Port St. Luciet Fla. 33452
?ART 1. OEATM WAS CAUSED, Rr1 ~ENfER Oalr ONE UUSE TER ER+E ?OIt hl IbL A!O ftM «t.u« owrtr :
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t rtMtN, •au NOW IN1URr OCCYRRED 1 twee wlwt or Iwwf• Iw r•n / pe r.n N, Irtr u 1
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Igp1 ~ 111 M. 1U t
1N1URr AT WORK Of tN11Nr a Now. r•er, srettr, rwson, LOCATION 1 eraln p e.r.e. ro.• cIn oe rO.N, •t.re 1
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CERtifiCw110N-MEWCJ?E fxAMwER OR CCdONER a+ Nw ass a ?r roY. o. a•rw rwt NCIMM ~Iq tiOMWwCfO tN•e
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CERMIER-NAME /trrt w
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c..;
•tu~ 4
,,.Lester Archer MD ~ G ~ - G-~
lrsttr oe e r t M O~
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MAK SS- Eerrrt~ t t !y i
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IoCAT1OM cm oe roww sr.rr
BURIAL, CREMATION. REMOVAL EMETERY OR CREMATORY-NAME
r.St.-Jo_s_eph's Cemete_r_
y ,.,Galesburg (Knox Co.) Illinois
TM Removal _ _ -
OATE^----- ~+orrw. o??. wu~ fUNERAI
HOME-w.~uaE AND ADOR[SS ~ snto oe e.r.e. wo., tm w to~.w, sr•n. tr 1 ~at, ~~~~ucie
yy Jan. 5E__1978 Tle .
V.S. +rBTZ TUNER ~EQOR//- _ REGISiRAt--SIGttA rUe[ OMt etCt`t0 ~t 1 •1 tGlNeu i
Fev. 7/78 TH !>iC,~ ~ ~ ~ 1M 7 ~~h /l .t ~ !V_
I hereby certify this to be a true and correct
copy of the Local Registrar's record on file in )
~ the Martin County Health Department in Stuart, ;
~ 1 Florida.
~ (Warning: Not valid unless raised seal of~the
Martin County-Health Department is affixed.)
Archie McCallister, M.D.
= . • i County Health Officer & Local Registrar, ~
r -
~ ~ - Date Deputy Local Registrar
.
)
t
~iL~v ~;:G RECORDED
t•~Y, ~ - -
~ 43280'
•?9 FEB 2 Aidl 1 i : OS
- tr r~ "'r~~
CLERK CiR~i;l i ~
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