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HomeMy WebLinkAbout0378 ~ inls Do- eT~- ..,ao oF Nu~rF+ CERTIF'1CATE OF 1~EATH -L~~`j~5,`~ co~es • BUR~~ •-~F Y{TAL iTA716T1C0 67ATH FlLS NO, . 1'a°ll°°- FLORIDA ~ ord r~eq H)ATH NO REOISTRAR•8 1`l0. propaelr tXeCLt~d ruCE OF DIATH GODH NO. L UiUAL RIND[NCQ(WIa~I+cawdliatl. I/lyfih+w+: Rr:Ls~t~i~R•~aatwiuiea) ~ ant r131 a. fAUntY ~ e. STATE b. COUNTY ba P,,~.a _ St Lucie 66-12 Florida St. Lucie iq qtt- ~ . a. C1TY. TOWM.OR LOCATqt1 t, t5 PLICE OF 6FATH CITY, TOWX, OA LOCATqN ~ . t. ~5 RESIDLNCE . ~ ~•~nept ~ INS~OE Cry~T~Y LIMIT51 . INS~DE CITY LINIT51 - + t.~l~. Fnrt Pierce YES~y r:o? Fort Pierce YES? r.o~ ~ , d. NAVE Of (J~~ fa AapiJOl, diet 1l~ett addrtu) ~ e. IENGTH OF d. STREET ADDRESS ~ ~ OH Il FARM1 kOSPITAL OR S AY ~ri Ib YESO ?~O W ~ . _ _ IMSTITUTqN g~~ pierce ~Sem, Hos t. 2~1a s S. Federal Hi-Na . ~ 3 NAME OF . tY~~t tlid6lt Le~t 1. DATE Monf~ Uar Ytn? ; ~itir~~`°,r~n Bertha S. Hart ~TH Aug. I9 19~9 ~ ~ ~ S. SEl( 6. %'O~pR OR RACE 7. 0. OATE OF SIRTN 9. AGE (In ~twt 1F lA1nEA 1 YUII 7 trND£lt 2~ Ku. _ MAPRiEO C~ NEYER MARp~fD? " fYf bb ALa ) ~ ' ~ ~ ^ f~ ~ T Xwt?a DeM H~.u. X:+. . . ~ t ~ + Female '~tl}1~te ?+n~cwco OIYOA[ED NOV. ( ZS . p 1 a! n 1 r ~p~. uSUAI OCCUPAT~ON (Ultt ltnd ojrort doat i0t~. K~HO W BlSI71ESSOA IKOVSTRY 11. B70.THPUICE (Stalt o//ortl~p tuftnl~ 12. tlT"dfr OF WxAt OO~J,yTRYi . ! ~ 1 t ~ p~ r- Qrrtnp mat oJ rortiny I~ft, ~rre if rflinl) ~ ' ¦?nant housewife own ho~e Haverhil~ biass. U.S.A. D2atk !nk FATHER'S NAME 11. MOTHER'S NAIDEN luwE or t~per~i t~~ Jahn Unobt • ' ~ 15. WAS OFCEASED EYER IM U. 5. ARM£O FOtiCESt Ib. SOtUL SECUHITY KO. 17. INFORMA i{iGlU1TYRI E Le Roy Hart ~ t tYu. v. rnlsa~ IIJ isi. ~:r, w. r i~+e~ erriu) • . ! . no 38-0 -~fb88a .~da~,. ~ Pun- r•1 ~A1{~C 0/ OtATM [Enlt/ pAlj OM tiYH ptl ~iK/M (0), (b). a4L (t).] Ih7ERVAL BETWEEM ' ~ OtiSET AND OEATH ' • dlr~ctat DART 1. DEATM WASGJ~V"XU'sYe I+,, ~ ¦u~t fll• ~MMEDIATE UUSE (C) yn,~j~j]Qjg~~$(~~,1$~~Q]~, ~ ' the eer- _ 1 t~tfcste Conditio+u,i/aad. J~~y~p) wlvar, Wlt.~l metastasPs 18 ~s• •!LA tAe rlicA pue r~u [o ~ ~ 1 o c s 2 oAort coart Fs). ~ i. , ` re6latrsr tlatinp lAt uadt~- p,~E TO (t) a•t tr.np nrrt le,l. 1 •lthin 71 Z ~ PART 11. OTHER SeGNSi7C~tR COti~KXiS COn'Iit!bIRWG t0 DUM 8UT NOT REUTED t0 THE iLRU~iiLL OiSEASE 00lDti10l! Gf!'pl ~ ART f(~) . YrAS AUTOPSY I LOUTt ~ ~ 'PCRFORNEDI t~r d~ath ' ~S ~ ? ' OT Dlfot• ~ ^ ~ ~ ~.pEKR18fHOWINIURYOCCURRED. (En/t~A0f4~tOflwJYr/i~ l,'I~PLrt!loJiftw.tl~'• ~ I •~kina ae~ ~ ACCIDENT SUIC~DE MONICIDE _ ~ C, .p . _ " . ~ spo~i- u ? ? ? - t, ~ . ' ''~+1 - - ~ .ba of ~ 21k. TI4E OF flovr Mont~, Dsf. Yru . - ~ ~ . ~ ' DOd~. V i.•UURY a. a. ~ ~ . . ' - + . 'q P. e~. . . , t, . ~ Nd. lN1URY OCCURNCD 2Dc. PiRCE OF INIURY (r. iR a oAou! Aanu, mJ. CITY. TOWN, OR LOCATpIt ; 46i) TY STATF ~lt WMKE AT ~ N07YYH1LE ~ /arn~./ufory. Knrt, elJEtr bfl/., tt:J . • .i ~ . - . YYORK AT WORR • - 21. /~tt~ndad th~ dsc~as~d /~om . to ~l~gs_ ~ 8~.~ 7~7 •nd /a~t ti+~ him ~/ir~ on . Ds~tb occur~ed ~t m on the datet~t~ted ~bo?s; end ro fh~ beit ol my know/od~s. lrom th~ c~~~ea ~ttted. ~ All 3t~~~ jjs. f~plLtTU1tE j •~e to D• 22D. ADDAESS 22c. OATE SiGNED co~pl~Gs ~ Richard F. Sirtnott ~S.D. 708 S. 6th St. Ft ~Pierce - 8 21 , aeeu~atf. ~~~u~ ~EMATqN_ 238, OATE 23c. NAME01'CENEiERYOACREMATORY ZJd. LpCATpN(Gl'f~,folex.acouq7/) ~£tolt) RE~OYLL (SptCt/yl 8`2~_ Delr Cremato De]ra ~each Fla. r . ~ V. S.~ 612 j~, NfaERAI DIAEC OR ~S SIGRATUR ~ l O ?wt~ppESSC ?S. Dl1TE RECO. !Y COCdL REG. 2b. REG157RAA'S SIGMATURE ' r 1 ti~Gi : t R••.'~66 Ro r L. rd Ft. Pierce, Fla. 8/2Z/59 Anna Les Denisan d.r. t.. _ _ _ - - _ - - - ` • ~ , - . ~ ~ , F!L I~N~~R~E~ ~ 1 t~eraby_.cerlify ~fhii ~to, be a true and cor~sct copy of the loca ~ ~ t`! fl ~ 0~ K . Registrors- record on ~ik in tfis St. Luci• Counry Health ~epart- ~ ~ merrt at Fort Piarce; F(arida. (Wa~nirtig:.Not~alitl unless raisod se~l ~f th4 St. lucie ~66 JA~~ ~ P« 2'~ 9 , > ; ~ ~ ~ ~ - . ~ Countj? ~{ealth Department is ~ffixed.) - _ _ ~ . • , ' - ~ _L4~.'~a2 ~ _ . . _ : ~ • ~ ~ ~ ~ ~ ~ ~ . N. D. MILt~R M. . ; ~ ROGE~2 r'~~l~i rt~1 ~LERK . i:,. County Nealth Officer 8~ taal Registror ST. LU C I L C 0 U i ~ t Y? ' ~ ~ - ~ FLORIDA . .i.~ ' .'t. t,v i ~ _ ~L, k.~„~„=~_ ~ Dat~ Deputy loce! Registr~r R~~~ ~,d,,,,,,. 800K ej ; • t ~ , - ~