HomeMy WebLinkAbout0558 465'722
state of Florida CEi, i~1FKATE OF DEATH
llepartment of Health and Rehabilitative Services F L O R I D 1l FATE Ef,E.Ei No._ _
VITAL STATISTICS R[GIlTRAR'f No
TYPE OR PRINT DECEASED-.NAME •rn• «w0u a•1t SEX DALE Of DEATH ~ «o«r», o•r, Ru r r'~
iN , Millard Lester Maples ?Male ,July 4, 1978
PERMANENT
SLACK INK RACE n""*~• «,cw, •raarcw uwu», AGE-uu u«o,a r n•a vwu I o•+ LATE Of RIRM /rp.a, o.., COUNTY Oi DEATH
1K. r went r nllZte wof M+. wows ••r•. "arch 14 188 Martin
Sa 7~ Se. se. E Ta.
rtY, TOWN. OR l 110N pEATH w.wa crl+ arras NOSTMTAI OR OTHER lISTIT - rw wpI w pwa., arw .+rn •rra r.vwla r
s?ua. rf. a aao
~o Stuart es 2d. Martin Memorial Hos ital
STATE W 4RM r u woI r« • , w.w d112EN o. WHAT COUNTRY MARRIED, NEVER MARRIED. SURVNNG SPOUSE r w ru., own r.we« «•ra r
coww+r WIDOWED. OIVORCEO ~ Wer.r
alfwlr+ca s Georgia 9. U.S.A. ,o. M1ldoxed
wrtl NQ•IIO
.,•IO u N•wr SOC!At SEC'1elTtl M!A?RER USUAI OCCU?AiKIN rwa •«o
o+ .+0aa Dow ew»a rwt w KwO Of WSEr1ESS OR INDNSTRY
O<cvuFO w - roaawo aw, hI» « apuao r
,:262-42-2412 Hi Maintenance ,b. State Road De
al f~oa»Ca NqY
•o..rffro». wa.roa Can urn. STREET AND f
RESWENCE-STATE COUNT1f Crtr, TOWN, OR EOCATION
Florida St~ Lucie Ft. Pierce 2408 Georgia Ave.
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fATMER-NAME )Iyt rrOp~ wt MOTHER-MAIDEN NAME IIN, rwN. 4f+
„ Charles Maples s Rebecca
1NfORMANT-NAME MAKW(s ADDRESS Htgp O...LO. rq, Car M qrr«, p•w, ir1
,,,Mrs. Elise Iia~nexacker ,,,621 S. ii Th. Street, Ft. Pierce, Fla. 33450
DEATH WAS CAUS[D RY: (ENTER ONLY ONE CAUSE /ER TINE TOR Ew1 f~A AND kN Ntia« O«Nt i.1t~
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Ewei R OTHER SI(3NMKANT CON01110NSo co+wno«. corwwrmwo q N•wr aw «o, rureo q c•rrN am« w ?u, . rot AUTO?SY r YES tea. rr«ar«o ~ ~
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{Vt!.~al~eM~~~1 ACCMtNT~ r ro«tw, Mr, nu r HOW INIIIRY OCCURRED I !«w. wNaa p «uon r« .u, . M u, asst y'1 ~
HOMKIOEr OR VlO~TERMINEO
ECM i
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20a 20b. 2'Oc M. lOd.
INJURY AT WORK MACE Of N1URY wow. r.w, frw+, a•oon, EOCATION r uaaa a a.r.o. rao., un oa ,O++a, sun a '
au.a+. n. a «o/ o+rrce aua.,.K. Iwearr
20e. 201. r+i-
CEttMKAT1pN- ro«n1 M+ +w aaorn» N+ reu •»O us+ L•+ «n./rN¦ unra O« r ow``~ie ..prl.tr an OtA,N pYeuueo a, o+a rocs, o.l a,•
fwY3KUN. TO r10.rrw Mr +au aoo+ ].t.Aa..M. rwora r o.w, .we, q .
21a oaca.a,o +w.. Z I -r 210- ~ ~ 2f e. 7 ~3 •a 21d. 2fe ~ M ?o was e.rNnr 1 +
CERTMICATION-MEDKAI EIIAMINER OR CORONER O« ,»a usrs or +ra wow p N•wr •»a NcaN»..•s raaaou»ca N•e -
fa•«w•nO+r p M a00+ ••wid Ira wrff,q•+rD», r» r+ pwrp«, ard+M M? +1•a wow
N•M OCCVMlO O« M O.w •«O OM q +rr! (•yy.rfr !r•wo
22a _ M. ?20. ,
CERTIHER-NAME
inn w qwn SIGNATW ~ Nwu p rrnt OAiE SIGNED r a~~
2~aVencent P. Mira~lia M.D. 2m. Guu /y~~ r,< S
MAR.ING ADDRESS-CERTYrtt slrar oa a.+.o crn a ra.» sr•n c
~.a5 fOfT 312. 27d
~li oar 1977, (T? RURUI, CREMATION, REMOVAL fMETERY OR CREMATORY-NAME IOCAl10H ern oa p•r+r fr•+e
pvua OVCVS rwCa+r
15'°'~ 2.a Removal :.o M_emo_r_i_al C_em_etery__ _ 2.~. Lake Cit Columbia CtyL_.~ Fl°rida
E 1 t)ATf rrOwrw, O•+. ra.ar fYNERAI HOME-NAAA[ ANO ADDf[SS fulln Oa r r e «O., Ut+ Oa rOr», a+Ma, art r Port rSt Lucie
f
,.d Jul 5 1978 ,S$o er L. B PSL Funeral Home 8 16 S. Fed. Hxy.
; TUNERAI ECTOR-SIGN R/_ REGISTRA]R-SlGwwr~q OA, Trr o or aOCAI .!Grit
j 2sn ~ ; ' 26a
I
~ ~ ~ • I hereb certif this to be a true and correct
~ = , copy of the Local Registrar's record on file in
~
the Martin County Health Department in Stuart,
• ~
. Florida.
a
' ~ ~ (Warning : Not valid unless raised seal of the
. ~ . ~ . Martin County Health Department is affixed. )
;~.I Archie McCallister, M.D. '
:,d.~ - County Health Officer & Local Registrar
r'
~ s:
pp ~ - ~
1 0 ~J U ~ ,J~.RT'
~ a'e Deputy Local Registrar
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r.
465'722
S ROGER F ^~~Ti."-~
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