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10- 21-80 ,>< 4 • UQ'p "'SELF INFLICTFn G,jiNSH(1T WQIJ[~'LL
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. nsreby csrtrfy thK to be a true and correct copy of the loca~ ~~ OEC -3 AM ~ 04
Registrar's record on file in the St. facie County Health Depart-
ment nt Fort Pierce Florida.
FILED !.lIC F.LCORDCO
(Warr:=gig: hot ~ ~.~d ur.'e5s raised seal of the St- Lucie ST.LUCIE COUNTY.FLA.
County Yeatth (Jepartrnent 1s affixed.) ROGER POITRAS
CLERK CIRCUIT COURT /~
RECORD YERIFjFn. ___
N. D. MILLER, M. D. `- y-~
Countat Health Officer 6 local Registrsr C~AO,yC
DAN ~ Deputy foul Reoistrar
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