HomeMy WebLinkAbout2386 • Y' ~
~ _ _ _
46121 ~
sate- Boars o2 Hestlth • CERTIFICATE OF DEATH ~ saa aiie Na _ .
Bureau of Vita3 satisties' ~ F L O 8 i D A - Re~lstrar's Ne- ~ ~
1. Pi.A~cs oir DEATH: ~ s, USOAL RESIDF~NCS t>: DmI.'iA81~ .
(a) cawts Indian River p c ~
erne F1QririB txos~s s~:.T_~4~A
f b) PractnM---_.. Preelaet it
o (write name. not number) (o) pb ae ~s F` Pier ~ _ R1 A _
(C) fit} on ~
~ Towo~9l'~.:BB soh ~a
x (e) Btreet iv .
(d) Name of hospital or lnsd
w (If not in hospital er 1mtltnuoo. write street aumties ae loeatiao) -te) Qtlun d Llbe'e(sn oounb'!* Nt]
~ (e) Lenittb at std: In hospital oe 7es ae ivo
W At pla« os den lgMd4 whettsQ sears, months or dais) TZ 7a. nama eountr~
: -
~ s. rv1.I. xAME o>r a~~n PEnRe AE~1-JAI:KSOti -
~ ; ~ : >s veteran. s (b) soda) senattY 1~DIGAI. e>es~C~tur -
a ~ name ~ !D. Hate of : srae~ llAareh ~q ?9
~ a. se= Female tw tee ~ ~ Y t~ 11:00 e ~ ~
sl. I bereb7 «s_ti4? that i atte:~aea the ae«ased -
~ u t. Stntle. married. widowed oz
GG a ~ i (a) Ii msrrled. widowed ar dtv«bed. husband at (or) that I Lst pw b-_. atha ~ ..i and
wQ a~ ` wife
that death oocure~ea oa the data and hone aataa above. Datatlea
C] d t (D) ABe o! husband or wife. >Z !Ihe 7aa*a Immediaa Cwss of
~ ~ 7. 19lrth date os -
y 9 ~ 8. Ate: Yeses l~[onths Dqa 8 lee than ow dq Dw to
p o 63 5 29 - nee
~ -
st. 131rthpL« (Cib. to or oouab) (state o: torrlsn oamtr7) (Include pe+esoanq adthta s months of death)
0
~ 10. Usual oocu
11. Industry or basin Maior tlndinta:
~ N Charles ed - °t _ °a°~°'
~ the sense a
~ 11 RiTthn (rile ate ~ ebartedtta~
~ ii Maiden d 4•
0
a 1a.13trth -
1Z It death was due to ezternai eeaise~ t1II >a the tntlowins:
0
N la. Informants Sites (a) (l'iobabb) AcMdeat: sutsida, homidda (sDectbr)
{ ~ lti (a) Ad er0 a (b) Date oI ocNrrep•••
f
~ 17. Biuil, cKmaticn ac removal (o) where aid mTurs «~Cta•!(~s ~ to..n~ (Ootmt,) (state)
~ 17 (a) Date 3~30~48 t7 (b) !la ' (a) mhi~~s ~ m ae aboat bom4 m !ham fn iadusttial plaoq
it. FUnerat Directorls Sigoa (8pect>y type o! Dlaoe)
v. S. Ro. • While at wort (e) Means ct inTur~
~ 10 (a) Ad
1st. i~ila+--T~-~
4A rs, sienature o P. rii'f'orc3 ~,y~
ar (a) Address ~ Si ~f.,$o
"I HEREBY CERTIFY THE ABOVE TO BE A TRUE AND CORRECT COPY OF THE LOCAL T
REGISTRAR'S RECORD ON FILE IN THE INDIAN RIVER COUNTY HEALTH UNIT AT
VERO BEACH, FLORIDA."
THIS IS NOT VALID UNLESS THE RAISED SEAL OF THE
INDIAN RIVER COUNT~f.-HEALTH UNIT -IS AFFIXED.
t
COUNTY H D ECTOR, REGISTRAR -
t ~ -
~ EPUTY REGISTRAR
y1rt~ ~ 461215 .
,w.-.: 1919 OCT -3 P1~ ~ ~6
r ~
fILEOINCNEGUX1~tU
. "-~:u, , ST.LUCIE CCUNTY.FIA.
ROGER POtTRAS - -
CLERK CIEiCUIT CO T
RECORD VERIF~ED-
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