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481269 II~ER 9JO PAGE i84 ~
state of FldEtda . CERTIFICATE OF DEATH
DapartEtseat of Iiea1W and Reh.MUtatiee 8arrioes ~ F L O $ I D A eT~Ta Ptu Eso._ -
4 v1TAL e'1'ATI8TIC8 ecotsTeAe•e No. 620
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TYPE OR PRINT
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,t. Removal NResurrectiotr~emetery „~lyoming, Michigan
t~~--- ~197r,...-__ r ~wrE=?~.~r..ro Aooass ~ •,•r•r w . ~ ~ t Miami Fla.
mac, eraria Lat na Brake #r1~:,r4Y~'" N{~ "Y St., ,
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~ ~ (TNet)y osrtify this w be .true a~ correct of the 481269
~ Registrar's record on fik in the St. facie County Health Dapert-
TrTent at Fort Pierce, Fbrida. I~~O NAR 3 I ~ t~ 23 ~ ~ i, ~ ~ {
(We?nfrTg: Not valid unless raised seal of the St. Lode • ~ ~ r n. }
County Health Department is sffixed.) ~ ~ ~-c i
FILERf•NOp~CUHiIlU -.,;1.~ ~ ~
SLLUCIE COtMTY.il14•
ROGER POITRAS ~ rn
N. D. MILLER, M. D. CLERK CIRCUIT C,O~II-IT~ , f N o
- County H with Offiur 6 foul Rpistr~t~avEP1F~E0~--~~-~s-`-""' _ f ~,,o ' ~r
~ ~ is-~7~7d ~ ~ ~ ~
pale Oeputr foul Reofstrsr c's ~ ~ ~ •
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