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en..rlt.r :lilli:=al Fox Annie Una~~ailal.le
1 MAS DECEASED EYER 111 Y. i ARYED [pOKC[ST K SCCIAI SECURITII Np. q. IN G MSIMTEIw!
Tn........,A...,/ u,IMl.wrrre~../rwW Poroth_- S. Fox
Yes W'rJ ~1 1! 0- 0-12 x~«t 1113 Camino `t F i ' e e
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tttl••t• ~I,d~l,.,,q.•r, oa To tA) _ A Fa~i ~Ciatlgt 8 Table
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r•alstr•r 'tom t4 sue' OOE 70 Ir)
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w•¦ r • r- ?ART 11. OTIE¦ SYIStKYrt GDNDITIONT COKtRIptT•i TO OtATN !IR NOT IIEIAT[0 TO 1NE TERYIIML OTSIAS[ C01tJ1TTDK GllEil w rMT 1(.) - MAS AUTOrSr
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t•• a•Atll TESO No QC
•r D•t•r• ~ ~ T ~ OESCRIf[ IIOM YW11T OCCURKEO (t]Ito R•Ir?r 1• rrr 1• Per 1 « Pwt 1! lkrA tt )
¦•Itl¦G a¦~ ~ ACCIDENT SYKIOE NOYK:I(i N i y
i 1'I"t- QD O l't. fella 11 ).~t ~ he ed -e or t +t~le in is ho~~e
IN •r 70r TIME os I/srr x..rA. D•r. Ye«
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20t IIUYRV OCCURRED 14e. rtACE Or NUUR11 tt. r-. III a .Ar•14i•t. Zp/ CITT. TOTTN. 011 IOCATKNI OOUNTII STATE
MNLE AT ~ NOT MALE l«T•, Tt.td• MK Etp., Nt.)
ttroRx ATMORK - Ol:le 1•'t. Yierce :>t. Lucie Fla.
- tl / •tt•ndd tAi• dsowwdltotn _ ~a , to •nd A.t ww >.I~ •4n on
D.•tA occurred •t At]Allt: ~ A _ i•: ~ tw on the dot•.f.t•d •Awr•; •ed to tA• b•.t o/ m~ A¦owNd/•. /tom tM uus•• •t•t•d
All ls•¦• ~ NStMTY(K
•r• t• lotr?rr M fY/tl Zm ADDRESS 1Ti. DATE SIf.NEO
.•.~l.t. a ~ Fr~lncis J. C~irbonara ='.li- 503 N. 7th. ;;tree'. An~~.
••t.r•t•. ~ RuRIAE. CRErATgll. Z~ pATE LIT. NAYE OF CEMETERY OR CREYATQITT 21/. LOCATION ((1tr. trwR. «
ttaRtp 18sY)
_ ~`rp°lcer4o~a~ 8-7-65 Yortl:+nd }:vet -teen Cenete v Portl.+nti Chautau ua :1 Y.
T.l. /!1! j1- FUIIERAL ouE oR s sTGKI?TIME .1t er' OJae ~ DATE RECD. Or LOCAL DEG. ti. REGKTRAR-S sTCKATWIE
!•v.llee John L. Price,Jr. Ft. Pierce, Fla 8-9-65 - Anna I.ee Deai~on, d.r. •
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~ ~ - 1980 -NAR -4 P!! ~ 24
1 all~wy certify thb m be a true~erld taon+ect coP1~ clf tits Lout
Registrar's ret~ord on file in the $t. Lucie Colxlty ~feeilil LEDA CPfCp~D
E meet at Fort P'laru, Florins. ~ UCI CPpAI~RA A.
' (1Narnirig: Not valid unlsa roissti leal of the St. lltc3e iLfRK CiRWR
County yealth pePartment is effixeda i~l~ YERif1EQ
N. D. MILLER, M. O. • _ ~~1~
- Counry Health Officer i Loael Rpktrer ! . ~ ~ ,
Loci iEDglstro? ~ ~ ~ . ~ ,
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