HomeMy WebLinkAbout0303 .i b'batt Board ~ Health ~ ~R~~~iA~ OF D~A~ State File No.
ptu+sun of Vital $tatLtia $t~iatrar's No. ~ .
49506 FLORIDA
~i I. HLACS O D L UBUAL RES[ IQICS OI DSCEABSD:
I
(a) Coenb Db:trkt No. Q
(bl Freciaet Pnelset :Va (a) 8au (bl Oowtb -
( rl wma not ¦ ) •
'i (c) City or/~r Cibotr f~~. f' (e) Clb or town
1Lwn /t 1~ ~I Town N (1[ oeu doe awe Hmita> wriu U )
-
th,7te of boapltal or Inatitotioa 1 ~i ) w
~ (It not to baapital or lartltutlee, wrlu street number or loeatioa) (d) Street No. ~~1~ 3 ~i a
le) I.restl o(< aW : in hwpiW o Itr}ltatlan ~ (It rural. ehe beation)
to tsi. caomantb / (e) It IoreiFe born, bow foes u U. a A.t 7Mre
(SPeeltf r sea», moatba or dasa) ~
~i •
w
3 Fl'I.i. NAME OP DECEASED r
• s (al If veterae, (b) Soelal Seenrib MEDIC CitR IC~ATj°N ~ ~Y ' i
-OdZ~ j+,p, hate of is 4f~ ~ 2 :
name war Na +
t. Srrr Gfl.~ 6. Color or raoa
21. 1 ber eerllfs tbat I attended the deeeaa. from •
6. Singe. harried, widowed or dltwrced 19~To _ ~ Y 19
i /a) 1f marrkd, ~rjQitwed or dico tuL i d of (ot)
~V flat 1 laa saw h,rdfl~llaUra on I .Z'I ~
rife of at
and that death occurred a the dau and hour tod abotre. Dantiae e
t t'•~ /~t:~ of hustand er wife, if alitre trean au dtxtb ~ •
`Birth date of deceased / ~
(moolb) (dal) sear)
~ :
a. Ace: Years 1loatlu Dasa 1[ lras than one dos Dna ~
S
bra. attn. Due w a
.
i~
t ~
9. [tirtl.F2aoe ~
Other eonditlona
(Ciq wn of 171 (State ~r IureiLn couatrs) 1 ~ ,
w ( Ilnel presaanaq wi is a m,:a:~ra of ddtb)
i^_•. GcsalouuPatwo ~ _ ,
atajur 6ndinca:
I 1 t Leda+ar .+r bt.,iada t
` I of oPeratlan Uaderliae
t ~ 12. tiame wblcb daa ~ f
a ~ (Giro data ofoperatienl A
aboald be
, i x. itrthplau -
~ of auluWS e6a?eed ata- C
' - i 11. 3faid•n name _ - tbtkalls. ~
i ' Ir
I - ! 15. P>irti.vlau ~ 22. It deatL eras dw u e:tetnal cau~n, 611 in tLe fol:owioe:
I 1G. Informant's Si •n tore ~ (s) Accident, satcide, Itewttdde (apedts)
a
IGlyi Addres a .i (b) Dauofoeeurrenu
• - ~ le) Wbete did tajttrs oeettrt
1:. Aurial, a as or remosalT (Citsorwwnl ((:onabl ISuu)
(d) Did Injuttr AMY[ is Oe about huraq ua lartn, in indta,trial Place, in
1 17 (a) Dau T ( 1' - ~ PuDlie PlaeeT _
]s. Funeral Drreetor9 Sian e _ l~___-___.~ iS1K.,ts tytY of P:ace1
13 (a) Ad _ _ ~ _ _ II Khik ¦t w ! - -Icl *t-•na or injuts - _
~ 2J. 5ijnature _ M. p i. Iia e
15. Filed 19 Y 1
g®~ Local Itrt is:rar I~ lal AJJreaa -_lY.fte Signed ~ •Y
t - r ~ /r2 - ~
mot. _ S
_ _ _ , 4950'6 - - .
rereby certlt'y this to tk a true and correct copy of me t.cx. ~3ttU b~~ ICJ ~ i'• 3~`
registrar's record on file in the St. Lucie County Health DeP FILEC ANC t:c
^~ent at fort Pierce. Florida. CCR(:ED
ST. LUCIE COUNiY.FLA.
Not valid unless raised seal of the St. Luc ROGER POITRAS `x _ I
n (Warning: artment is affixed) CLERK CIRCUIj LOUR '~`'r
County Yealth Dep , '
RECORD ~'i P.if;ftl_
N. D. MILLER, M. D- t,` .
GDUnty Neaith Officer & Local Re41Rna' ' '
` ~ ~t~• a
0 r~O` l ~
y Del Deputy local Reaistrrr
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Btl'Ok JJU PbGE cX~
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