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State o[ Ftonda CERTIFICATE OF DE~AT~Hr~ ~ _
Department of Health aT,d Rehabilitative Services F L O A T D A 4W ~ 1~A7E Fll! NO. --~-.-t
VITAL STATISTICS _ fee~isTnAa•s Ko 368
"'rP~ OR PRINT DECEASED-NAME •Ili• _ .eexl 1•n SEx DATE OF DEATi, ~ roNrN. Y••, •eu l `
=Fianale J 13
?ERhthNENT
BLACK INK U?CE ~la• NIGaJ. •rllK•N ILY!•r, AGE-1•n Yaoel 1 •e•1 wee. 1 M. CAIE Of Iltlle IreNIN, N•, COUNTr Of DEATN
lK. . fncrr 1 alrw•• 1•lusl rof ,s Iloual nu 1
~ t. Dec. 23 1931 T, Saint Lucie
6603 CCTV, TpMIN, of ttXwiiWe t>E pEATM INfee cm wn t10SMAt OR OTHER NSTTEUTION- 1 r Nol Y1 uarl, ¢m aan .1e NYwla 1
- _ f.eeY• •es a .10 -
Te - • . Tc- - Yes Te 218 SOl].da Drive _ -
STAIE Or IiITM . r NO/ w Y.s . , N•rl CtitZEN Of VvNAT GOIRt1RY~ MAIMED. NEVER HARMED, SURVIVlfG SPOUSE 1 r vrlN, 41•l r•elN N•W / '
calwl,r 1 wDOwEO. DNOICED 1 fflcn 1
~fJa aefwllcl I _ t. _ j~_'__ ,o. ~1'T']~ _ t,. __~~dl"n~ M. tS___ -
,,.IO a p•111 SOCtAt SEC'M,TY NUMtIEI USUAI OCCUTAt10N Ie•w a,le o/ 110M OOIN 011/11/0 rplr p IINp OE N1SwEi5 0I WDIISTI1f
oCruNfO 11a rOfrrlf 11N, Few Y ll0a101
473-32-867 ire ONm )Eiome
1fi~oe.lce ploy 1YSel can 1Wr1 STREET AND R
.c.nfK1N 4EStDENCE-STATE COUNTY Crtir. TOV+IN- 0i lOG?TtON -
f fner• •el w No
i1C Port St. Lucie ib Yes 218 Soli,da Drive
fAtfOt-NAlrf r/lye Neon ~ ~ ufi MOTIIEI-MAr1EN NAME refr rloal - uu
u e s.
- INFORMANT-NAME A ~ "-'F M•~tlJ<• ADIIiESS If1Mer O. \.I.Y MO. Cr• W q1/N, fl•1!. tr1
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218 Solida Drive Port St. Lucie lal,orida 3345
TART , OEw1N wws CAUSED !Y: - ~ENfER Onto ONE CAUSE /EI tME FOR NL EbJ, wn0 (1/~ \er.rpN`a
wf w er
,s U1rf01•q wne
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CONO„/ONT. Y •Mr, 1~ ~ i- 1 ` ~f ~I'
1YM1(M O••l 1/1l e0 1~t
t..Nn•fl c•Yfe fa. Y11f •o, a N • eoNseo11e11ce w: '
l•INO c•Ya l•lt
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1AiT r OTHEI StGftrtGwT COffWTtOf>S: ca.aaoNS co111e»11,Ls w ier ,Ye 1/0i ,ef•1l0.O C•Yfl 61•M w r•n r far ALTO~St IF IfE3 rep aN,INef e
1 •el b 1101 MOlpO 111 N1elWN111O
E + ~ 14,1 /400~•tY
~ Atap[/fr, f0E A f rONd, er•, reu 1 - HOw IN711IV OCCURIED uNlel 11•eilM o1 1N1Yn w r•lr 1 a 1•!r a. lflr n 1
OR 1trOETERIfreED ~ . .
20a 200. 20e. M- 200
1NluRY AT wOMC rlACf Of NIUIY •r Now. 1.¦r, fra/r, r•cro,•, IOCADAN 1 Fran 00 l.r.e- NO., an M ro1.1., fr•a 1
l lfl(1/• rif M NO1 QNIp l1Af,., l1C. lfaltY•1
IOe 30r 200 -
CERTIFKATtOfe- .1oN+N o•• rlu .oN•1 0.• .w •11o usr s•ly / cols/ere Nor wer 1111 OEATM O{e1AlEq .r aN n•cl. ON
I ?M13K4Na TO rp111N e!n ,OO• •1111 p•M 1N01101 i/A•1l, •110, r0 Ml
~ 1 •rnl.oeo rre ~ ~ ~ ~ ~ ~ Ej ~ / ii p r• aNe1r1e0Gl.
2'a oue•ue 1pr ~ • a tib ~ ' ~ vr0 tic. ,J V ~ ~ - 2te ?t. • M •o all e•Yfln1 sre
CERTrtCwT10N-MED1CAl ExAMwER OR CCIRONER oN an l•fn o1 fIw a p•M ~Ne pt N1 wy Of•0
e••rw•roN p rA 1001 •110/0• rrf Y1•efllWrgN, w 1n p1rIN)N, - •1•l NOW
p•/r O:CW1fD ON sr'o.r! •110 Ye q nQ C•uSl1f1 fug0 -
21a _
CERttiKRA- Bn of ,Nr SIGN TtIRE ~ .t. ~ ~ w r~
,~j OATS SIC~D /roN1Y, o••,
7]• ! • - ~ 1 - f - ~ 270- f 1 2x. ..1 c .i, i 1 t}. ~
w?rtFFG SS-CERT r ~ E. O frlen o, l.1 o No em ton. ~ ; ~ - seye ~
BPS fO1r1 31?. ?b
Mar f4n. tA? WRiAT, CMiMATIOra, RE••OVAL EMETERY OR CREMATORY-NAME IOCAIIOIe an a tO.r1. - _ furl
claraf OOCVS 1fMCN•,
Fo •n VS•tit21 - '
O TE au1 FuNEttwYtiO - w ~~Nw w ¦ri 110. cln q lorN, lure. ul/ - R r101~
2•A Jw~e• 1.7 1.978 2S1 BQX 777 Ft. Pierre, Fl 33450
iuNERAt tHRECTOR-SIGNAru~E, REGt ss~~NN~~fiTIME . oA,f ttclneo sr ,otu nmfn•l
25D `-fi-•tf%.' Y'~~ T~ jc ~ t' - ftLCisc..? ~1- ~/~•I ors rF ~G%~ 2se - n 15 1978 -
1979 SEP 28 PH 12~ 16
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FtI.EO alto Rl:co~la~o - ~
ST.LUCIE000NTY.FLA. - ,
ROGER POITRAS - - _ -
CLERKCIRCUIT C T
1 Mr>Dby osrtify Phis io f5e a true and correct copy of ~t~t1EP.I~:EQ.~~-,. _
Rspistrat's record on fife in the St. Lucie County Heahfi Depart- ~ ~
rnent at Fort Pierce, Florida. -
(Warning: Not valid unless raised seal of the St. Ltxle
County Health Department is affixed.)
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N. D. MILLER, M. D. - _ -
County He Ith Officer d. Local Registrar
/.f 7y ~ ,
D~ Deputy Local Rea~cf•+fr P~~~~