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lnrw~ tlAnErIC• F L o R ~ ~ A IOCA? EtIE NO.
ME DECEDEM~i1?ME ftESt WDDLE tASi SEX pAl[ d DEATH (x•., Orr. I".'/
W M!M
.EEtR:RENT 1. SI6UR0 E. NELSON Male ~A ril 5, 1979
EI/K.t YdC LACE-. E . Wct, w4E--l.M WiM./ 1ltDEa E YEwe 1?DEe 1 DAV MrE d NtTN Ex... O.F. r../ COIINit d DEATH
AIa /we,sl~ •t 1lf,.rhl (rraJ MOL MMS NDYES Rt116.
. W i e 75 ri 1 16 1903 r•- Marti n
GTif, TOWN OE lOUT10N d DEATH IIOSfiiAl OE OTIIEE tEanTV/gK-rte. (E/ .M 1. wEr. I+. N.'u W N•Erl !E NOSI. of 1?6T. tfwdeey DOA.
Stuart r~ Martin Memorial Hos ital In atient
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~ _ STATE d EiliN (l/ w:. GTQEN d ININi ODUgiETf MAtRIED, NEVFE MAtt1ED. SUtylY1N(1 SIOIbE 14 •~rr. w _ _ r"'•1
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I,~~wt tESNHNCE E- Norwa USA 10. Married iE. Ma Geor e ~
atif•e aawsEa SOCinI SECUtln R+stREEe IeWI aarAtlON (cw t:.d .(...t dr drw uw d EusINEU of IRglSTEY
I..I D IR OfAM w wtw Ei/y rrul Y r•Rir~l i 1
UREED iN
..•=lii~t~i-~,,~ t~. _ _ 1~.. Owner Jewelr -
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wCMiSSION. tFLOEHCf--STATE OOIMTY C/Tt, tOYM1 d IOCAiION tEEET A?O N1{Wft N3iDE C!n IIM,IS
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1e- Florida t•~ St. Luci a tk Jensen Beach I•dLot 15 Wi ndmi 11 Vi 11 a I•• No
rATNEE-NAME rIRST JAIDD?E IAST Y01NEE~IigEN ?MME El6T Y1001E lAtr ~
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ts- nknown t• Unknown
INfOE1tANl-/LAME /rFM r ra.11 Il1IX ADDEEf6 SttEEt q E.F.D. NO. Cttr Ol 101tIN SLATE [I?
IF•- Mrs. Mar Nelson tr. Lot 15 Windmill Villa e, Jensen Beach Florida 33457
EUtul, pEMATION, EEt•OVAI, O1NEE /fR••Ur1 CEMETEEr OE ClEMAiOfr-fMfA! tOC1lTlON UTr OE 10wf+ STATE 3
t•• Remo 1 Buri al IE~.Ha Yal l e Memorial Park t.R. El i zabethton Tenn. i
• s ~ RgNEGI q! fi/•rR•rr fVREEA? NOME !
AYCOCK FUNERAL HOME
f+-- ? i~ 95 N. E. o i s S re 7' .
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2 Olet+ oId d•• y rr •wrlJ ~ .ccviwd q rr riw, doN rd M•r •i'r M r ilr teuMl.l .`.'•d.
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r ~F s e rEONOUNCEO DEADlr.. D.,. rr.1 rRONOUtcEO DEAO re..rl
NAME OR ATtEIlOinIG /IRrS10ARR IF O1NEE IIMN CEEitNE! (TFM r pW/ r =
?v Td. ON !N. AT l M
IDd.
NAME AND ADDEESS d CEEriiIEt IRItrSICtAR'!, MEDKAI EXARRINEq lTFN r rri+R/
n / c a-RAM r- 1~ /l t Z e N: /i"~ ~ ~l l ~ ~3/jt- lls- A ~ T ~ t) E -1 ~ ~ ~ t/
tEGISitAR • • OAiE lfCE1YfD Elf EEGtSiEAE /x•_ EirF. 7r.1
Apri 1 6, 1979 '
Ir wNr T.. INMEDtAIE CAUSE IUr[a OX[I PRt[ CAOf[ IQ rJ1TL !D (?A AIRD I.1.F M..~..• rlrr ~
N'NI('N WYE '
t IMMEDIATE r~* ~ ANr ~ ~C ~N~ P~N/~(.• ~A 7 ~1 ~ • ~
€F uusE NI
STATING illE DI/E 10, Ot Af A 00?6EGYE/rCE OR ' MNnal betiN+wwR..d dNMi
~ uwtnrlNG r
~ CAtiSE tASr ~
I w c~i~cgA-Ai TN~Ai~~~,~,•., ~fGf-, -r lIMM,Bnu~a~. ~ I
y l OUE 10. OE AS A ODR6ld1ENU d. i 6rrw1 UM+NS «NI vd dNM
f€ ~ M
g • AUTOKr rfrrelt WAS CASE REEFttFD TO AIEDICAI ~
IAtf OTMf t SIGNIFICANT ODNMTIONS--Cr.AN.,~ ewdr~6.1ME r dNi4 t,M eM nNNd N aw'•• 0•'•e'^ IAEf 1 W r.. r r/ E1fAMiNEE rfrri/f rw r Itr1
f tt MvGCAi2T~E/~L TN~/7RcT~rprv /hAcJ'IiSo•Z/~TrON Sv/y~n•FRF Ts. Np r..
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Ir.ce.~?~I)]i~~ ACCep(Ni, SI/KiOf v DATE d IW Wr /Yw. in. T•./ f101M d INJYRII DESCIIEE IIOW INMr OCGUEtEO
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IN/YlY AT WOtK lfr..+h 1rr 11ACE d INMr-AR 1,•Iw, t•,_. •wrr. Ncrry, •N,o .II+Id+M, LOCATION STEEET Ot E.F.D. Nr. qn d tOWN STATE
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d:.. orcvs n., nr. 71-
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f ~ Y 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,
• _ ~ Florida.
" -
s ~ '
(Warning: vot valid unless raised seal of the
- ~ l~.artin County Health Department is affixed.)
• Archie McCallister, M.D. ~ '
County Heali;h Officer & Loea1 Registrar •
. ~
i
at ~1~~ vdi~u~:y Local Registrar -
~9I9 HAY I g t~
. PMI.4~ q
lE A U kE 0
• .4445'73 '~o~c~~R°n. t~o 47tT PACE T~1
I CLERK C~CWT CO n _ a ~ r ~ 1':; 'Ji
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