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CERTIFICATE OF DEATH
' DepeAwewt of t feal?11 e4i Re?rL?l?I.Uw $lnrkw KA?t Pllt NO
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Tr?E, Ot ?nNt IN r1e"'r~r'!'Ler`rl'r° I?taliTRAR•i NO. 270
?tttiANlNT INK OKEASEG-NAME heal .Ifo.l ua SEIt OwTE OE OEI?TM a .o»1r, ewr, r!•e a
~ CEORC:E DUGI3~ Q~K Male , May 15, 1973
RACE arwltl, utoaO, wwlK•ar rraer, AGE-Ma1 Irr.ae 1 reu a..r«e 1 n•r OATE O? rItTM aro»1rr. e.r, COUNTY O? pEATM
lac, 1 anevf r Ml4rr rre.ua a wa. ern wpllfa •?we ~
Vfiite 73 k l Jan. 23. 1900 r.
6602 CITY, TOWN. of l T TM way/ cm arwa At OR OTM~ RasTITU tOf!- ar rrpr w lrrwf, cr•f arlrtr w wra+
sncur rfs a rrp
Ftr Pierce ,1 Yes T. Ft. Pierce Memrfal. Hospital _
STATE OE RItTM r 4 »ot w ar.l »..l gTIIEN O? wMAT COUNTRY MAtR:EO. NEYEt l.ARfsEO, _ SURV1rIN6 5~011SE r r •rf. am r?yl.. aw! r
D~r~~c~~ cowrna c.~ wlDOvrEG. EtNORCE~rancrrl tl. J1ael Elizabeth ~dy .
vw.a ualw»n E. Pe~ylvaru~ f DSA ,N I?larrled
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u.rs, w «.ea SOCw S[CW?iY
MIarV'ER uSUAI OCCU?ATtON .4•l er.r o? •rou cow owua .wa, or tln0 Of MISwESS Ot tNDVS1tY
xtwae w wparro wt, l•e» w Mrrte a
`a^M~• 375-OS-4224 Tool & Die Miakes
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t _ RESG/E['aCE-STATE COWIIY Crtlf. TOMM. OR IOCAT1pN rrsy. cw+ awa STREFT /~?N,,Y~,,w~E,,~~ may,
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14 Florid~$ 14. St. ~kCl@ IM a V • Pie tN ~ IN
/ATNEt.~NAAIE rrlar rrOH awat MOTHER-A?AR)EN NAME a4,! rrORa! aAa1 i
Is NicY~olas ChPxWak Il VaSkp
INFORMANT-NAME elAtfNCr AGGRESS laaun a ._li. wa, em M aow¦, ar•4. Ir1
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~ „Harold Davis ~ „~36 E. Brevard Drive, Melbourne Fla. 32901
?ARi t OE/alf? WAS CAUSEp tY: (Eh TER ONtY ONE CAbfE IER IfIaK FOR NL pL A/rp (c •?reoe:.:•r 1ae•.a
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_ IN/URT Ai WObC F'?wCE O? WJUfY.1 rorr, r.er• arru, r.[rolr, ?OCATION r aanla Oe !.r-e..ro., u4 oe aorr.. slwn 1 ;
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CERTIFtCAT1pN- oOrrir Mr rW t rOrafl o.r 7lwe t Mar a•V »+Mlle .u•l OM r Oy/yr~/r 114 DEwTM OCCYe[E •7 M ru(!. O» aN
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Ite oeu•ala rec.. ~ !T?e ~ 2R ,l ~ ~ N tU. 7t.. M. ao a»! e.l,vlal sand. _
CElTIFKATION- EttwMRVEt Ot CORCMEt: o».ma ua.s a r..e uo,r a we, iw! oaeloart ns wono,/..caa Nu i
re•rr+•1ro» Or ar! eoe? •rao/W M r.aarleano», rr .at Orr•10», reorna Mr rru roue ;
Dear OCCarelO Or W M4 •rre M ro rrl Cwrafral aa•no.
SIe _ ~ art 11~ N.
CERII R-NAME a n StGNwTUtE uule a r GATE
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AGOQESS-CEtitit6t znltr a e r.e. uo. c. aon+ / ~ .n tr
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RW1Al. CREMATION, REMOVAL _~CE/IIETE~.R,Y CREMATOiY-^NAME 'l ~rWy,N~,..~ ~y,V1V w^1rwY+» v' ~,,_sa•n i
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~ar~ NY. M1{.. ~11Vet WlL ~i4 a/G4LVZt 1~,C~"'~ W.~ iL~:111C3~
r DATE rrrowrr, e•r, nut FU!NE RAL MOarE-NUaF frlD wGdaf55 saeeel oe a.r.e. »o., utr a ro~», gwre rrr 1
w Mla~ 15 19 3 >s~~ ~ ft~ME? 901 N. 7th t. , Ft. Pierce, Flcrcic7a 33450
Y. S. 6612 EueuitA -SIGIMIUlE -S+GNwnxf OAtE RtCEIVW
Ror.19T0 IA. ~ r ~ y~y Y~°;•Y`'"'
~ hereby aertiiy thb to be s trvs snd aorreet copy of tfie t+occl
tTcgistrar's rooord on file In the St. turfs Cocmty tioattfi De„~rfr ~
rrieM n fort Pieros, flortds. _
Rr
(WamirFg: Alrt valid unlsss raised soel of the Rt
Crounty tieshh Department b ~ 4xts r.` , _ - ~ _
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FILCC :-~s[ CU~i1i C
Si.llk".lCCfU`1TY.F[A.
RGGER POi i R:.S
CLERK CIRCUl1 CO:iR l//
X341 p~ X07