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pTY iSTATE OF BIATN (O.~Y7./wp US.1 C/T12EN OF /Cwwlryl ~ MARRrtO. NEVER MARWFD• W1MM'EO. LAST SPUUSE (/r.~h, p.• =rNn,:•rrl
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yct •sto SpG,AL SECWUTY NW6E11 USUAL OGCNPATION la.[ u11fl of wtY1• Dor[ M1[Lw5 rJSi M KIND OP BUSINESS OR INDUSTRY
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iAi NER-N.IME Fe1[ET 1[•00.E t•sT MOi HER- MAIDEN NAPE i~aT •••DOIS las?
George James Green ~:mily I'hi ] liFs
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Itif (>.iMANT NAME w!AIL'NG ADDRf 55 Iir w(lr CA wt D w0 4r. cw tcw•1 !••rl. 1+~1
Mrs. Anna 2. Breen 65 Wnlnut St. Stratford, Bonn. 0.5!,97
PART 1 DEATN WAS GAliSEO 8Y: (ENTER ONLY ONE CAUSE PER LINE POR 1.). (DI. AND (c1
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PART 11. OT EIER $1/iV1F IGANI CONDIl1ON5. eu.?T.e•.s erwiw sf,r~we rD ee •Tw NT wDr wt_.i[D ,o e•:rsl 4~•[w :w sAAt 1 ca T A;JI OPSY K YES ,•.s _tw[
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' _ K Record Ink. PL AGE OF INJURY Ai K'Y[, r••1, Sirt[T. ~ LOCATION fltalT ~R wt D we t.7• lw 1Jww St •1[1 ' $URGF HY RtIL~ANT iD C~. ~.~"'i\•~ ~c''ii'+1 Ci. :V I:GV lT1
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be sent to the _ --i_- _ _
(:ERTKIGATION-PK15•C!AN: ,[Dwt1, p•t •EAR r'_:wTw C•t •[•A ~ 1 DF ATN OCCUFaEO 7w - ' U•[•`~~ ,C tws
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CERTIi IER -AAME n••[ M rwrwtl - - ~ ~ ~tiAT UAE ~ • e y
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MA1lING ADDAF SS --GERilF1ER srw[[r Cw wt0 Ib -Y Ur• p rCwM St•Tt t•. ~ CATF S'~-'F 1•~wqr~ t•
BURIAL CREMATION, REM„•YAL i CEwIETERY oR CREMATORY -NAME i IOCATIp[ c.r. c. -cww
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=y _ °urial ; ___St. Michaels Strztl'urd, ~^*:n.
DATE ;.rJa~ w• •t•~ tUNEAAL HOME-NAME ANC ADDRESS 15'n[• cw w•c wo a*• t^n~ sr•,t 1:n
_Fe_ b. 27,- 1978 i .Dennis dcL"Arcy lnc. 2611 Main St. Stratford, Bonn. Gb~1S7 !
~ ~ FUME Rw .a CTOR OR BA1YE AME OF EN3AFM£R 1• eo:• w•s [~r•: vFD ' l:c V[E E_R
• ose h Lonahue ~ 1`j2
Troy SERTIFICATE RECErvED FOR RECORD ON ~ eT rFGcS:~AR
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'r_ RE3Y C R`PIFY '"HAT ",'HIS IS A TRITE CC1?Y (1F "HE CENTIFICA^E RAC ~I'-'rD F~7R
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ATTEST: * - Y '
Pr ~t3, AL STAT~' CS
JUN 101980 _`-~~`l_ r ;a~"
SATED: ~•j ' ; .
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~ (Not good xithout raised seal of ^erftifying O'fff'cial-) ~ '
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E 4905'70
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FILED ~?h0 FECp~•
ST.LUCIE COtAiTY.FLA.
~ CLERK
CR~11T RAST
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