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:ka. t;.- eTt?n eo~?RO o~ ettr~.tlt CERTIFICATE OF DEATH Sor1-i 04-23059379. ~
se.aa • wRtau or vn~ etnTlsvtcs ~ sraT: eltt rto.
1. a r..- FLORIDA
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~re~atl~ R ,t0.
arta.Ittea 1. RtATN COOL NO. ~•Yi~R~R[tloiNCtt~ta.p.n.tw` %R...twNt..d.ir.tw)
aali •ill -
?e ~laeed '
la Pe?- - R Cm. TOwN.OR tIDtATK1M e. a HEACE OF OEATN e. Cm. Town, oR IAGITIOM a e RESIDENCE
aswo¦e INSIDE uTY uMlrs/ _ INSIDE cm Ewas+
t11e~ _ F - YES No p - YES ? No ~
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Tk ~ (t/fM IR kM/td. /it lbNt./Bat) IENGTN GF d. STREET AooRESS ON A FARM
~T~ Ft. Pierce Mem. Hos it ~a sl 12 Rio oista ~s? ~
1. MARIR N Fbee AUddk - - Laet DATE XaaN Dq Ytat
( ~ ;"~TTHEW N. KUTZER, JR. ~TM A ril 20 1962
SEK f70tOR OR RACE 7. MARRED NEYERItARR1E0 OATS OF RIRTN AnG~E (ra Fetle t U.a7[R I YW IIMDERM NIi
Male Mite wloowEO? gYORCEO Jari• 1 1914 r 4~'I) x..a. v... N... x:..
•1t. 3,
t t k a: r- OCCUrAT10N (Qtee /tad yNw1 /eat toe.. KRID OF •USINESS OR alousTRY 11. RMTNF~ACE <SI'ak w prdp eaaatrp t trrltEll aF NNAr DDU!tlRrt
arty aMtt yNwtW tyF. wea r/rett?M
¦•¦•¦t Owmer & rator F - T t~ _ ~ _ A _
.laalt !wk il. FATHER'S NAME 11. MOTHS Y MAIDEtI NAME
er
t»a~rftee Matthex M. Kut~e Sr -
- 1S. wAS DECEASE4• EVER •I u. s. ARMED soRCE51 K socuLL sECURITr IIO. Q- at t aow?TVRa J aW. Yates. -
IFar. r. ar raliyw> u/.....:« /.w ,?...ww
No Addree, -
trraarel If- RAlltt K RRATN (1sl~te? aarl aae taaer per 1iaeJ~r (A). al(t).) - INTERVAL RFTwEEN
d 1 r ae b r FMT L OEATN wAS CAIRED RY: q~aE~ ARp OEATM _
•aat t11. IMMEOUTE CAUSE (a) $rorchonneumo~a _ 4-7 S
tb eor- -
t'='e't' • ti•ar• ouE To (et - ~:g~astatic Carcinoma of Color.
.ItR el?. „t(~ ~ e~-ta _ 8 Months
1 . s a 1 .ewe eaue a). _
.sl•arar - t1e ouEm(e)_ Carcinoma Ascen colon 4 Yrs.
altsi¦ 7R tFtIF eaaae tact. -
lOdra at- ~ FAIIT tt. OrIQ S~CwfKw_ Nr CglprgNS ppMrRMUf11S To otAn~ Sur Npr REtAiEO so tHE T[wrola oKUSE taMNTgN G1YEN M FMi i(a) . wA5 AUTO?SY
f' FERrORME01
tar aeask - rES-D ~ p
er litero - 29a~ , - ~ DEStRI~ 1IOIr NUURY OttURRED. (Eater aa/ure • r to Part / r fart I/ 6es ttl.)
aaklnj .wR ~ ACCIDENT SUN:IDE HOMICIDE F
~sel- D - D p -
ia et - J fit. TIME CF flwe XaaN, DaF. Ytar -
aaa~- 3 IwuRr w. - -
p. s.
Za. R41NIY OCCURRED mr. RACE OF NWRY (e. r•. to Y alwt Aarae. 10J- CITY. TOwN_ OR LOCATION COUNTY STATE
1aMILE AT p IIDT wNIEE p b•I. /utwF, cued, yke ety., ett.) -
wORK AT MOIIK
~ • 7 attaedad tM daoaswd /rom 1977 , to t 2 and tut w. Aa. atira on -
~ - DaatA oeeuerad at 9:30 A • en ovr tM dat. atatad atlwa, and to tn. bast o1 my 1<rno~tad/a, /ron+ tM rauaaa atatad.
All fteNe MOIIATttllt#
are+ to 1e - (DrF?es ar tYk) ?ts. ADDRESS ?Ie. DATE SIGNED
o..,l.t. • Meh*in ilolkoxsky,i~.D. 808 Orange Ave.,Ft.Pierce 4-24-62
a0erratt. ~ tt111aK.~~ ~ OATS 23r,. NAME OF CEMETERY OR CREMATORY ?3/. LOUTION(4Tt,,tara.artaa
aDY.I (S NJF1 aql (bate)
~`e)nova'~ 4-23-62 Northshore Garden of lietno Libertyville, Ill.
T. t. gels j1- FLNERAL OII "S SIGNATURE - AppRE55_ 1S. DATE RECD. RY LOCAL REG. ~ REGISTRAR'S SIfiNATURE _ _ • '
R••.1lss Joseph W. Yates, Ft. -Pierce, Fla. 4-25-62 ,Anna Lee Denison, d.r. -
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- _ f579 SEP -2 I Ali 4 3 - '
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FIt.EO Ati0 F~CURUEU - ~ _ -
ST.LUCIE COUNTY.FEA. r- • s
RdGER POITRAS ' `'%3"''~ -
~ ~ Q~
- -J~LERK CIP.CUIt COi31~~!~!' ••}~~'zM
hKeby grtity fhit 10 he 0 trot atld COtreCt copy tl~ the LOpf~"D VERifiEC_ r' ,r•'r . `L `
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Rpistrar's rticord on flls in~the St. lucfe County Heahh D~peA- :,~:i ~ - : ~ . r-'~
mNtt at Fort Pierce. Florida. 45l~~s ; ur ~ _
(Warning: Not valid unless raised seal of the St. lode _ _ - • Ir'~`~~. -
_ s`
County Health Department is affixed ~.lc f~
~r.a~f '.Y.: t'.
'+)iys~ ~ 1~`S.sw
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County Health Officer 6 Local Repistral - '
- Deputy Local Reo;s+.,Ir
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