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CE}2TIFICATE OP DEATH -
Ikp.fl.r~f Yt I It.utt .NIL to IN.IaI;INllre Gtt•Etn FLORIDA ITAT! IiL! NO.
IN\hNRY /N 111 ll Ilf
11 Pt. CSR 'f:~/l ;H wau,w mrsr,N,wa RE6ILTRAR'0 NO.
PiRMAr{t NT INN r~r, c~., . t.,,t r.eetl !•t1 Ir4Nir, O•t, ¦Lwtt
,It n.N.,,Y. IYR r""' _ a ulc owu a pEAtN
Irls.iucla?s John _Ileitr _ uc;l~ ~ al ~ Au;;ust
l8.
1Q73 ,
RAC[ wN•u, t.wu, •rlaK•N wWw, AGE-tsl YNne,
~ .t•a Y:!o~l 1 oat DATE OE RrR1N Irp.,tN, Ht, COUNIt' Df OEAIH
fK. l aNCw t Inrre•, t qu\1 ..p\. paq rteyU riw, tt•a t
_ ~ White 40 ~ k E,~l ?15,...~~ l3roward
CIIY,1Owit,
OR~tUC~11ON
OF'OEAtEI wt+pf tln tNarf EpSMwI OR OlE1ER Ir+S~~Ut10N-N.wE /N Not Na I+rNI,
cNl fnelt .,e «Ywlt t
/ sNCN. rfs w No
~~•-,~•.t 1?1;t1'~~~j,~~._ _y~s l~.ntation eneral Ho_s~~tt11
SiAli OI ttRln IN Not w Y \ • , N•rt CIII~EN O/ Wt1Al COUNTRY MARt1ED, HEYER r•A7:41E0, SLRVIVIN(' SEOIISf IY Sul, 4nt watOlN wwf t ~
tOYNUr r N D, DIV'QRt:[ . s•ttw r
alua a,•rr.lcf R Georgia . U. _S. A_. arriec~ _ tl Be_atriee Pettie
...nl our•ttp
+„tr „ tNarN SOCUU SlCUf11Y T.tUtwRER USUAL OCCUPAItON Iftrf ar+0 arO.r 00•tf pYtING ro\r Or CkiD OE WSwESS OR INDUSiR`(
OC(.•.t/p w ttOO Nt, lNf, frlN N 111+a1D 1
+~t'°+~t~=w IE2G1-42-7014 tt. Self em to ed t>, pr //~t ~j ~/~y„~
tt s~; tw,l rlrpal ~S'~\L ~.tltJ.YaL~-
'D'"'ss'"' RESIDENC.-STATE - 'COUNtY C11Y, TOWN, OR lOU?IION wswf an tlrttt Sit[El AND NWMRER
t a?lCNt tlt W NO
Il. Florida tt,St, Lucie If. Fort Pierce If/ No IlrRt. -1 Box 698
MiNtR-NAME nat aupe/e ua MOIttER-MAlOEN NAME rrit twat usr
IS Vdilliam h'1 1/ ~
INIORMAEEt-tJAME Jtar?llftC• ADE.tESS Isneu oa a.r.e. rto., art a arN, sr.n, frt
Iq Beatrice Pettie DOU las 1>1Rt. -1 Box 698 Fort Pierce, Florida
....o.,_.
PART 1. OEAiN WAS CAUSED RY, IWIER ONt>< ONE CAUSE PER tWE FOR (o), /'6/, iM0 (cli urwltN oNtlr •NO et.e.
ti. r~ta•ri
oust
t•I rain to tl•ur
N t l
towon/ors, a attr,
trrlCN e•rf nfl 10 Ai
' Irrle:arf c•V31 lot, M t0, Oa y • tONYlWtrKi er:
a,aIING ,rr YNpta-
IUNe C•Y!! l•9
kl
CART OILER SIGNNKANt CONDtt10NS: ctrraworrs coraaNaw q ef•w sw Not att.ne to c.YU e/reN rN raar t wt AUtO/St' N` LIES rlta nre/NCS cc.• ' :
frfs a Not a/waee IN oe,artNlNe oaf •
~ es IW eta,N es
z
RNE~eMtl ACU~ErrT, Su'bf>E OR OA trpNtr, D•r, teur NOW IIiJURr OCCURRED Ittma w,IM M tNwar tN ?•u r O. nu N, urr pr
f10NtKlOE; OR IrrAET[rwtNED
t ~at~uo ~ M ~/Pri~.r -last cnntrnl end struck bric'~Y.
INIURt AI K'OtrL PLACE OI TtA/!Y . wo.t. tart s n, rKroar, lOCA11p~ r snot of • r.o_ N an of roar«. a•r[ /
uncut o. Nor wKt utw.ttc. rs•fctnl 4, ~Z 111 S ~ fC,C~ south of exit IS/
>o.. ~ es :RI. Turn ike a ~ ~
CERIMKAIKME- roNtr pat ,w I r17r/.1 o.r .[u •NO usr sa. nr. Nra cute ON 1 ao/tNO wr rN~ Nv YtwIN txa.ua.av •r rat flKf, W r.f
Rtlr3ltuN: TO ro.rrN wt n•a soot una parr. tNtwtr own, •No, a tNf us• ;
f anirefe ,NI - Or rt aN',ralltpf~t, L.t [
_ - fl. eeee•sto n.~.. !1S !it !1/. 2t.. EA. so ae e•Yx•s+ t•.-e~
CE[iUKwilpft-~DKAt ExAMWER OR CCSCONER: orr rwt lasts a r.le rpyt p a•N/ rNl aclaNr try raorroYNceo a•o
fautwat.ON Or tJOr .N,/pa, Mt r,rltr,i,•r,p•r, M• NI OftN1pN, r[NAN e?a Tf•t rOVa
f ~ OtaM Oc(Wr/p ON M Wrt •NO pUl W rNt Caytl.\t lraRe. -
C[RitINR--flNM(
~rrH W raven e~lc1 SKCetAt JA ~~____._l~ GATE SIGNED /.•ONZM ~~~•r.
• V
».Geoifre~T. Mann, M. D.Fxami • -j~'Y,~E_-----N"7. ,,,Au ust 20. 19i;
Ml1><W('s AODiESS-CEt/lf1Ef s•ret+ cr • t o No at• to rorN
~1 E~ 5?O1 5. W. ?1st Avenue Fort Lr~uderdale Florida ~~312
' ?-p~ i tuR1AE. CkEMAtKkt. ItEatOvwt Ex[tteY OR CatMAloRt-NAA/E tOCA/K1N un a ro.N atwn
F
jam'/ l sncn.
_ Iw Remov_al t~?Fort Pierce_~emetery tlr •ort Pierce Florida.
~ ' +i 1 _ DATE rNo..•N, o+• n.r, fUNERAt HOME-NAME It1D axaESS u•!u oa e r No., ent o• ro+~N, seen t/rl
Au_ _uSt 20, 1973 _ • „t IIz#ird Fun. Home, 11?2 Pl, W, f;? st avenue, $unr~:.c, Florida 33:13
S. 1612 FUNERAL ~kTCM-SrGNAIU/l REGWRAR-S.GN.tiUiE ~ ~ oarE fECll~f7 tr tO:at ?EG.Stut
f. a v. l y 10 IH ~,[~t,.,-E• Is. %i1.1 ,i
f •s .~!~C J Eve %r~ t.t./~' , :
~ . % ~ 'J
. ~
~ `
~ CYaiTIFIEU CO?Y ~
f
~ I hereby certify the ztbove to be a true and correct copy of thn Local
ReFietrar's record on file in the IIroNard County llcalth llepa~rtr.±ent at
F -iauderdalc, 1•'lorida. 4
=`_'ry`•:(sq~Y.~ Ndt vtEl£d unl^ss rai;~ed seal of the Bror/urd County Health
; ~ GD~part~ant is affixed.
~ ' C ai~y H-altb~~fl:~cr_r iinci Locai
::cGistrar ;
.1... 1 ; ryr ~ ~ ;c . , . r
•t
' • - ` ~ ~ r;~ ~ llcpttty ~soc~tl itel;ist •ur
/ ,
SUOSp~
' _0 fir' 23 :1.2
Si.LLrlt CCi~TrftA.
R06ER POiTRAS
CLERK CIRCUIT LGtAt fJ '
FLtcpn~[ctsrtt'-._
X339 P~ 554