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This instrument was prepared by 4b3901
Chester B. GriNin 1124A No. 2nd St
fort Pierce` fls.
RE: WILLIE GLENN, DECEASED
Lots 20 and 21 Meyerhoff Re-Subdivision of Block 96 in Section 5,
Township 35 South, Range 40 East (Garden City Farms)
ral. tiTAT[ nowlto or IItL?LTH CERTIFICATE OF DEATH
roaaa a ~t/R[AU OI VITAL [TATIRIC[ RAT[ FIL[ NO.
?•si1 FLORIDA r~ -
ord rslR SIRT NO. REOIOTRAR'fl NO.
prepaPl~ 1 KAG< 0? Ot/lTN COD[ NO.
aZattitad 2 YWAI Y[II OtRC[(RAwr l.a•r•/hrd //.+.1ar.r,.t~ RarraMer M~ta~.....•.`
tad rill COIINTr • STATE 3. COuATr
e. plae.d e _ Florida 5t. Lucie .
1 a prP- A. CITY. TOwN.OR IfKAT10N t. K PLACE OE DEATH t. CITY, TOWA. OR tOCATgN t IS R[SIGEACF
alnrat INSIDE CITY LIY ITS/ INSIDE I.~TY ,~v.r5t
tile. I C r[s Ro[) Ft. PlerCe_ r[s _ N;~--
d. NAPE Of (/f Rat is ?atrita/, /Re afrtN •dlrtN) d. STREET AUDRE SS
HOSPITAL OR
INSTITUTION N^tl'Q. ilO S~~~. _2~2_fS_~/CL 1
3 p/IM[ 0/ ETrat A(iI1/t Last t DATE Alortl IMP )'iz• ,
n~
~
~i~l '+Jillie Glenn STN Lvov. 25, 1.906
S. SEX 6 COLOR OR RACE 7 MARRIED ® NEYER MARRIED? ~ DATE OF .IRTN 9 AGE Ilw,tsra i UAOER 1 YEM UI17E./;. `.P
iatt Sirt4gl y,~y /Jtt/ Nwr. I V.+
t s • 1?.ale Ne o wltX)1EEDp avoNCf:o JdnuarV 5, 1913 5 _
p 1 at al ~ IOa. USUAL OCCU?ATgN (QYt tial a rpt pat IOD KINDOF WSIRCSS OR INDUSTRY 11 lIRTNPLACE (1Taft er p?tya terRtrFi 12' C1/IZFA M aN?T OWti'R~•
• t t A pr r- frrir[ . •sM y rartia/ hJr, erta iJ retirtd)
aanant COIA.:on Labor Lon Shorcm~,n Florida t..S.t:.
Blaek tak 1;. FATHER S RAM[ 11 YOTNIR S MAIDEN NAME
Or
c~p..rta.r Unl:.no~?•-l b.rlttie i+n:t.
IS. wA5 DECEASED EVER IN U S. ARMED FORC[SI 16 SOtul SECURITY NO 17 INFORMANT { .IONATYII[ Sad1C C1CRl
I Car..t. tr •nawtwll .t/ M•, h•r w Mfr. a.n.nl
Yes ~ti W i~2 ?;i5-16-555 wur..1 ?cit)2 ave. , iQrce,
rrnaral 11 CAt/ti[ OP O[ATM (F.nfa aaJP eat carat p•r firr fo? (Ill, art IrL) 1NTE Pa AI eET Mf E•I
S 1 ratteP PART 1. OEATN NAS CAUSED RY' la r OASET 4RD LCATr.
tMYED1ATE CAUSE ql ._~l.-.{!.JOY El -
luat tlla ~ - -
cet eor- •
llrttasa ~;((.,,t.il•RP. otx To (el _
rlts tllr elid Pan rub t. -
t e e • 1 aAae tarot (a).
l a t r a r attetly Mt r r4r-
rittlln T2 ~ /Pia, tarot luf. OIiE TO (r)_ _ -
sours ar- PART 11. OVER SwrIE1tART CORgTKr6 CONTR1aUt RIG TO DEATH X111 NOT RELATED 10 TN[ 1lRMIMI DISEASE CdOIfION GMN W PART Intl WAS AC?C ~:.f
Itr daatA YES[] NO_
T
~r Oarora S ~ a~-uliLh-b:3i)--- iwrtic
. Rk 1 nti an7 ~ ~ ACCIDENT SUICIDE HOMICIDE DfSCRIlE NOw INJURY OCCURRf O 1 F.rrrr ra•-.r o/Irjrr, is ifot ! or Ya•t )I o) irra re i
goat- trt.
A or 2Dr TIME OF //0111 A/arfll. ns1. Yfa? - _ _ _ - - _
tadT' ~ IRIURY a. IR.
G y. •t.
W
~ 20d NIIURY OCCUMEO 21)t. ?LACE OF INJURY (r. P., iA r aMr/?o•It. 20/ CITY. TOWN OR IOCAT KNI COUNTY '•'A•E
WHILE AT ~ NOT wNK.E ~ /arla. !actor/, atrtN, aefrt DIIP., tlt.)
wO11K AT wORK
I
{ 21. I attandad tM daoaaaad /rom ._~OV • ~ . to \iOV . _ 2_~I~ and btt saw Jhlm a!(re on -'~OV • ~
~ DwtA occunad at _Ij m on the data atatad abo•s: and to tM bast oI m~ Anor/ad/s, /rom tM uute• accred
A 11 1 traa 110,IATY11[ (/Jttrrte a tl?kl 22A ADDRESS 22t. DATE S~GNtn -
ara to N
-..pl.t. • Martin G Gould N.O. Fort .Pierce, Fla. 28 ;.ov. ~;6
t e e rratr. _ ~UIMM.. CaEJUTgR. 23D_ DATE 23c. NAMC OF CEMETERY 011 CREMATORY 23t. LOUTKXt (t:i/P, tt4ra. or tarrtP) Garr:
R[RWY lSDtr1/Il
~ Burial 12- -66 Pine c_rove Ce:cete Ft. Pierce, Flom da
Y, 9. ~61D 2~. FURERAL 011 S SIGIIATURE AODR[SS 2S. DATE RECD. 1Y LOCAL REG. 26. REGISTRAR'S SK.NATURE
aa•.ilisa A.T. Stole, Ft.Pierce,Fla. 11-3V-66 Anna Lee Denison, d.r.
x}63901
Ilereoy ~Y IA1t to ba fr'IN an0 ODf'Ir1Cf Dopy Ot tho Wce
zen:-.Ir -r•s record on ffie in the St. tube C+,untr llee17+1 Pan-~~ ~ _ T 2~
_ me- i'o• r Peru. Ftoride. ~
! (Warn-nt;: !Jot va,id vnlesc raised coo! of the St. Ludo ST~I±;C:~~•'r~:;;.Y.r~ ,
• Eountr NeaNh DepartErlent Ic affixed.) ~OGi=I~ r~G' i ~t_•
K D. MILLER, AA. D.
County Health Officer b loco) Registra/
pe. Loco! Rdoistrtlr
y
'r
• - . ` ~ X19 Y~cE 579
o~'~K t
NEILL GRIFFIN JEFFRIES i LLOYD
_..Ari TI PF C`
P O BOX 1270 FORT PIERCE FLORIDA 33450 - TELEP 10NE (305 464-fa200