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trlt •twT[ eoAnta a~ tr[AL11/ CERTIFICATE OF DEATH
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•i••IIt•d ~ ODUIITY t. STATE 1. COUNTY
`w' St. Lucie 66-1 Fl i t
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! w . ~•r- 1. CITY. TOMtl.011 EACATK)N t. K RACE Os 0[ATN t. CITY. TOMN, 011 IOCATKNI f. K RESIDENCE
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rllel. F`t. Pierce YES[ NDO F Yie R r 1 rESp lam
NAYE Of (ryNw b Mgitd, /itt abtet •/bsM) t. LENGTN OF d. STREET ADDRESS ON A =ARM1
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IIAMt N FLaI NI//tt L•d DATE A(a•tA Dq Yt«
K~«~+•~) James Isaac Kellums ~T" 21 l~ b
SEX L 001011 011 RACE 7. YARRIED ? NEVER YARRIED • DATE Ot pRTN A6E (IN ps•ra • la~Otlt I YEAR IIMDCR N Itei
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t r t i • vale White wlDOtrEDI~ avollcED pu st 18m 18 8
p l Alwlt 10.. YSUAI OCCWATaN (t7iae t(w1o/w~art fault Imo. KN1DOt' WSUIES5011 iNOUSTRY I1..IRTNPLACE (State «preyw tatlRlrp) 1 CRITEII Dr t/IMt 00U1tTRtt
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••w••e Real estate evelo er Real .state Indiana U.S.
?laak lwr 1 pATNER'S NAPE It. NOTMERY YAIOEN NAYE
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t,p..rlt.r Isaac Rile Kellums Jane Alve
1 wAS DECEASED EVER Iw U. S. ARYEO soRCEST 1i sol:ul SECI1RITr No. 17. MI • NYMATYI[ ti .w • Yates
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~lr••t•r ?ART I. OEATN wAS CAUSEO.Ye ONSET ANO OEATN
...s ttl• IYYEOUTE CAUSE CarCinoma~ brotlchial :Months
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PERfp11YE0T '
o r r•t•r• ~ ~ l m0, pESCRIaF: IlOrr INJURY OCCURRED. (Is'll(er wdws tJi./•rp h Pwt 1 « Pat 1l ken lf.)
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20f. INJJRY OCCURRED IDr. PLACE Or INJURY (t. I•. !w t? al?wt Maas, PD/. CITY. TDwN. OR IOCATKMI COI;NTY STATE
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TtORK AT 11011K
21. 1 •tbndtd tM dw•Ndlrorn 12-10- , to r - •ndlut trar Au'm •li?• on 9-21 ~7~ _
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All lt•w• NOItAriRt
• I • t• r• UkYrte N tY/r) 11A. ADDRESS ?ti. iwaTE SIeNEO ~
~..~l.t. • itichard r. Sinnott ::.D. 708 S. 6th. Ft. tierce Fla. - 6
• t sttt •t•. CREauTION. ~ DATE Z3c. NAPE OF CEMETERY OR CREYATOIIY T3f. LOCATR)11 (fYp, lwrw. M ttawTrl ($tYt)
8EIa4YAl (SpttlJr)
Burial -2 - 6 Ft. tierce ~elnetc Ft. Pierce r la
9, t . ~Alll :t. fUNERAI W E OR S SK:NATURE ADDRESS 25. DATE R[CD..T I.OCAI RE6. 7~_ RE6KTRAR'S SIGNATUIIE
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tt~.lt?sa Jose h Yates Ft Y e F _ _ D
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,Hereby oertlty this to be a true uld correct coPY ~ ttte l.~oce~
Registrar's record on file in the St. lllcie County Heahh Depetl- " ~ ~ ,
Piece. floride. ~ ~
tnent at Fort
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(1Naming: Not valid unless raised seal of the St. Jude
County Health Department it affixed.) c~. ..r;
mot,
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N. D. MILLER, M- D. _ a ~
County Health Officer b Loc,~1 Reyhtre' ~ b~., '
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. Deputy local Reo~°+~R? ` :
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~ ST. L'3'. ~ ~ l A.
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