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sa?t~ l~oa><a of Health CERTH'ICATE OF DEATH state File xo
i ; Bueran of Vital Statistics F L O 8I D A ReQistru's No- ~
t. la.~cs ar s$: s. vsvwt. i~ssm~~or~ nt4cz?ssa Q~J _~)/,J'
(7amt;~ ~ _ut.enct: N (a) ar~+- ~ ep) C~o~mLT
' v (D) Freem (w n.m~~ nugoDer) Peectnet x (o) Ctb or Ta ~ v ~'L~LC'e"~
_ (d) sar.t x
(d) x.m. opt tw.pttat er m.tt Ylt)
(I! oot m hospttil ae mstiritttoe, write atsest number oe 1oeetlon) (e) Qttsen at roeelan oounitt?t
i5t (t) Iwe~fh d stye In batp/Li1 7d ae no
td At n)see at ~ 7d. name oolmtr~ T1~"7a ~ / -
(8p~7 whdher months oe dgrs)
n
a. rvt~r. xw>ta or _ .
~ ~ a it .aseran. ~1, s (b) sloetat se~,aKv ttsani ct~rtricw:io>
~
~ ~ a name ..ar / ~ xo !D. Date of Death: 1Lon IDq
a '~-y~ a_ 0 Yeas / 9~ 9 ~ ti
t az 0. ~aioe ae !1. I tLat I attended the deceased tr^M
0. amri. mrrtse. widowed or ~
F a ~ f (al tt m.ertad, wtdowd ar dtraroed. hmbaod of (or) tbt _ 1~ caw ~i~s,a / - 02, s. ti R_ ~
" .a ~ wtae ~ that loath ooo~rd oa tha da4 and Lac staid abase. D~rattaa
3 ~ g i tD) wee of hurbaod ee wlLe. tt a]F.~ Ceara momedfate oauae et
x ~ as<tn aaa of (mmth) (dq) a?•~)
~I + rd - _ -
w , 0. A`e: Yeas 1[onWa Dqa >Y law than as+a dq Dae to
~ J Sl / 02~ Dw
+ A ~ .
~p 4
~ G ~ f. 131fL11 (Ci('. tOiYD OT ) (s(a(e Ot OOIIDtl7) ~ (II1C1Nde DQY~naII4 Wlt~hln mOQt11a Cd deetlt)
{ i ~ ~ le. LTniel
E 11, Indwdr~ oe 1Wor AndtriBe:
f ~e ad opera UaAerl ~
ZZ -
~ wblebdeati
a ~ ],0. (QtYe date Gd OperttlQn) ebarsedeta-
w li 1lafden °t
! Q ]8.
f!. It death was dw to aeteraal esusea, SII is the lalLe+wfns:
10. InLoravanYls 81Oia -~ui1~t1 ) (Penbabitj) Aioctdant. aufctder LomlMde (sD~4)
~ u (a) S~ pds ad oseutran~+a
(d) Nhere did tglurs caeca!
1!. ata l.l. er.matton er gmotl (eMS ar town) (Count) (8tate)
i> (a) Data (b-.~T /
95L-9tT (b) i~laa ~ ~ !a ae abort tame. m laxm. In tndu~trlal planar
u slso.rat rllreetas'. - ' (t3peab vp• az tom)
5. No. a Y (a) / n -`I~. r i/h~e d woet~ at mf.a~
l!. rwe~_ ~ ~ . 1L D.
44688
X979 : : ~'I ~1~1 I ~ 19
+
nerecy c.rttty this b bs a true snd correct copy of the Loin Fit.Ea t,t;t. ~~i: i' tu~U .
~ ST.LQC t<Ull~~~:t'Li.. '
Registrar's record on file in the St. lucle County Heahh DepeA- ftOU'~~~PL11• ~R>4S u ~ ' ~ ` "
~I,FRti'CIRj;tJtt COURT
a rnent at Fort Pierce. Florida.
(Warning: Not valid unless raised seal of the St. lucle
County Health Department is affixed.) ,
i
~/f ~Ir ~
N. D. MILIER, M. D.
County h(palth Officer a Lotstl Registrs+ n.' ~ 1 ~ a
J
~D~ Deputy locsl Rea+~+?„r R~~'1JI~N TO:
- Home State Title Co.
~ l~ Q e 1950 Lee RoFad, Suite 105.8
3 ~ 7 ~ ~ .3 S l Winter Park, -~1ar~~+~ 32789 ,