HomeMy WebLinkAbout2947 State Board o~ Heahh CERTIFICATE -OF DEATH l4tate File' No.
Btiisean of Vital 3tatistiq '
FLORIDA BaSiatrar'e No.
1. PLACE O! DSA~ IL USUAL Ri;6IDlitiCS O! DECEASED:
(ai Coost7 ~,.{r~a'll.t~ DistrMR lie' O~ r ~y '
(b1 1'reelrxt Ptrelnet tio. (a) State ~~.,.aej~,. (Dl Coongr/_:A""C•~-t`c..cr
• M name, sat ) y~ ~ ~
(e) To:a 1~bwa .i ? ! Y (a) Cib ee torf,~ 17`000U- _
' ~ tIt ettbMb eitl ar fawn ! ita• rNte~t
3~ trA~)
' ~ (d) Name of hospital aft imtlt • -
titnot is harpitaler ttrtitatfiea, wrltaat atr tx er beatloa) (d) Sttt«c lte~
C (e) Lenten of ataT.: In aaptt.l er (ttafltalie~ ~ llt rnr .hire <xa ' )
W Ia thb eommanip ~'•'e (e) It tottta~s Dorn. lw ions In U. S. A.t - >.ean
t3padh w lreara. month or dqa)
i. Flrt,l. NAME UR DF.CEASSD ~
~ ~ ~ i ~ la! IL retrnn. (b) Social Seeuri EDI 1. R IFICATION
~ namerrar _ ~~7.-~+ lia t?0. Date of DeatD: Monti` ~ ~.T-Dat L'~ -
A [ a _ 1~ y~ /yV 1< hoar ~ - 1tin+t!e - - - M.
~ a ~ ~ 1. Lin ti. Color or tape
'I, A a Yi. I hercbf txrtih that I attendrd the dcr;ynt frntn = _ -"_~1' r v
~ ~ ~ . R. Sintte, mauled, widared or dhotroed ~ lY _To i..: t.,t'(' li+" ~ t
v-- 6la) If married, widowed tx ditroroed, ? of (tx) T'---`
:Y a ; ~ ~ that I last ww Aft. alias oo _ - I•••+-- t
A ~ rife of - ~ asd that death occurred an the date and hour stated nlrcre. ~ Unrat,~n
Cs. ~ f i
~ .r !3 I~ R Its( Aze of hnsbard or wlte, It slim t7~a I eatW of deatD _
~ ~ ~ 7. birth date o[ da=eased ~ y'-c"O - -
a'. ~ II •(month) (dq) (sear) _ = _ _ _
W .m c li-----
tR A ~ Ate : years Months Daira Tt leas (bas ame dal Dtte to i _ _
is7
~ ~i ~ ~ ' r,
j ~ u o ~i " " ~ ~ hn. min. Due to - - - - - _
J ~ ~ ~ . -
to F 8. Hitthplact 'F _ - -
r, ttltp,. on oountT,) (State t reitseountp)
• a ~ ~ (Include prctraocf rithin t m,nths of d. stht i
f ~ v ~ 14. i'su+1 oreuraticn ~ _ _
7 ~l ~ a l ~DtnjoT Lndin¢a: J t---~~~
+ 11- M•T ntrt nr hc-[rys
i _ - rte- _ of operat100a _ ( t ^drrline
3 c 12. tame I
• -Li l -1 ti.r ..n=e to
` ' err;, d: rth
+ ~ - (Giredabofoperalic.,l ~o~,s'd Ue
i 11- I:erthplace I
A :i O[ auto{s> - $eFa.rert ua-
.q ~ )t. 3tabien name. _ ~ tir~,cnl~r.
f. ~
€ ~ i' 7i l••. Birthplace I -
_ _ + 2:1. It dralh rru dua to ezternal causes. All in the foii.,wirg:
~C 16. Infurn:ant's Si;;nalure • (a) Accident, aakide, homicide (apreih)
~ ~ - r ~
f' ]5 tat A.!dress - _ . L (b) Uate o[ oeearrcna - - -
a -
l`-- (o) When .lid iajurs oecnrT _
1;. itnrhi. rrcmation or removal( - ~f- f»..? _.<l~Ti ~ 1 ,(City ortuxn, tl.~un!q. - -t:.:wtc?
T ~ / - r /d) Did injare oarur in or atwnt hems, on tarn,, in i wl.x-r.s1 t i; in'
t; tit Uate - ~ - l( ib) Plaee~ r. •.-L ~~~t_
' -I public pjsclt - - -
1• P•,r•:ai Itir.~t.•r~s ti.,naturr ~ yib~7t ~
~f / t5{x<,f3 tY;c vI f~1ac. 1
:y t,,, ;,.y!•e-.s _ _ ~ _ - ' .i While at wo/r~ct ~T (e) _lltewn: it~!arS -
V. B. Nn.4 IY. F,1. ! 19 r ~.~tr•. ~ i _ '1 tJ. SiAratare^'~i-~~'s- r fit- t:.
Lapl Rrtisutr I.t Aderesf ..t__.__:, t•:+;c n..i
_L
t.e~•(•t?y cef+th~ M!s to tie a true and correct copy t7F ttte l,oce+ .
, .n~f,r<i ~~le in the St. Lucie County Health Depart- -
rf the St. hxis r •
~>f
1979 t?AY -2 Aa i~ I6 . • ~
~ ~f1lE~A ~ RE T
HOED _ . - - - t -
~ ()equty local Re•n~-t•wr
P..rOR~YI~RlFf~O f~a
s
t ~'31f.~VV'
. s~~~~17' ~~~~294fi
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