HomeMy WebLinkAbout0415 _ _ _ _ - _
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TAt• De- BTATE BOARD OF MEJ?6TH CEF2T(FICATE OF DEATH _~_~_L ~ ~ ~
co~es a BUREAU OF VITA6 sl'ATIYYICO STAT6 F11E NO.
1°a•l FLORIDA
ord ~A~n BIRTN N. REGI6TRAft•S NO..
properly
tieCULOd ruCE OF OiATM CODE NO. Z. UfVAI R[SID[kC[(1?4r~f1rw~dfial. fli~uHfw~ww~ R~~fa+ia~Ww~~Aisaiw)
•!fl •111 t. COUMTY . STATE A. COUNTY
n• y~a~.a - ~
!a ptT- b. CITY. TOWN,(M IOCATqN ~S ?IACE Os OERTN t. CITY, TOWM,OR LOCATqM t. 15 NESIDENf.E
•~nent INS~DE CITY LI~IT51 INS~Df C~TY l~4iTSi
rt~.. F Y~sQ~ ~o? Ft. Pierce Rural YES? ~ai~
f, q~ME OF {!/iwf fw 11s~ptlal, ~i+t N~tt! ~l/rtu) LEMGTM OF STRfET ADDRf55 OM A FARMT
~N~.STiTUT107~ TA iM IA x YES ? !10 ?
Ft. Fieroe Mem Hos 1~ ~a s t. 2 Box
3. NAM[ OF Fir~l ~ ,{/t~{tt la~f 1. DAtE MeaU Da? Ytv
OiC~/11i0 OF -
cn~ p r~~.n Carrie Rachel Fer son ~TN Au ust 11 1960
S. S(7C 6. OOIOR OR MCF MAR111E0 {pl KEV[R M11~RIT0 D~~ OATE OF YpITM 9. AGE (!w K~~ ~~aR i ruu ~p~ 2~ 1s25,
/Nt l~lt/) Xwe4 O.M N~..~ Xu..
t t. Female Wh1t~ w?ooweo0 avo~ccn Se t. 7 1916 3
plalAl~ jQ,s,USUALOCCUtATqN (Qiet!(~tl~f~tN![~tt {OD.KtM00F~U21fsES50RIM:IVSTIIY 11.ltRTN/IaCE($~/tR/b~t1/ntM~l?/) 1.UTiZEMGfrMATtOIMfTRtI
•fth p~r- (a~ s~ek~/ra ?RffiJt,tat~IJrtltit~
~'ouse~i~`e Ft. Dnun Fla. U.S.A.
b1~Ck 1fk fASMER'S NAME 1~. MOTHER'S MAI~JEp KAME
t~p~rrit~r John 1r'ernian ( lst. name unavailable) Roberts
IS. MRS CEC[AS{D EYE11 IN U. S. AfIMED FONCE51 16. SO{Ul SEWIIITY 1q. 17. IK~OR • NaM+~Ty~[ J~W~YgtiB.q
~ r... tu w. I+.. .o.. I.w ...,..d ,
No Ad~~~ t. Pierce Fla.
~ iues ~ e 1 1!. CAYfi OI 6tATN (E7~lt? ~w1/ ~xt nwt ptr l~Rt/w (A). ~Rl (cl.j Irrt[RVAI sE7YfEEM
Air~etOf IABTL DEATXtllASLRUSdOlY: o~ ~ ~~ATM
.u.o tii. ~NM[WATE CAUSE Pr~eunonia R. U. & R LL 4~a s
th• e~r-
~ ouE TO (b)
:iin~ain+ `a°''~'""'.+r"•. Ru,~, Ap,~endi~x rr~.th Abcess ~j::`` 11 Da s
r~4~1 /us r ts l . _
I e e a 1 e~-"-.:. tsstt~~). } - .
r~~iserar ~Of~/ ~ ~w~- 1 p~ TO (t) , . . ~ .
t~t~/ «wt 1W. 1 ; -
~ 1 t~ll1 17 0 ~Al1T IL OTFG 5761KIC~KT OOH9(TqM3 COMTt1~lli1NG TO OEATN ONi M6f RLUTLD 10 iYK IT~rWI DtS[AS~ OOIO! 6{YO f ~MS 1(~) ` . MitS AUTOKY
. 1ou~s •t- ~ . " . IiRFpIlME~0y1
t~r d~atA t~ ~ S' : ~ •~FS? !~OLD
er D~toro 4~ l ~Qh. pfXpiBE IqW ~M1UitY OCCUAn[D. (ERtn R~tt?t • h rr ty fl (ttr~iJ
¦at~.a •¦y ~ AC[IDENT w~c~oc uowKiac / 1 ~ t~ : . - :
•pes!- ~ ? ? . J: ~r _
,,oe et ~ 20e 7irE or Horr M~t?, Dq, Y~o '
~.er. IlUURT A. ' _ ~
p D. fl. • • \ -
A~, INJURY OCCURRED ?~k. tLACE Of INJUIIY (t. ftt a~twsl Ao+sf, 2% CtTY. TOYtN. O# LOGTIOi1 . . M1T STATE ~
wn~~c ~T ~ nor wHnc ~ la..!«tar. ,r.ret. o~n btp.. a~.) ~~f~~:
- 1MpRK AT MPORlC
21. !~tt~nd~d fM d~cvaiad lwm . to 11 •nd b~t s~~ hfm ~li~~ on AUg • 11 ,
Dwth ocourrd ~t m on th~ d~t~ ~t¦t~d ~6or~; ~nd to tA~ d~at o/ m~ knovHd~~, /~om th~ uua~a at~tM.
~ ~I1 1t~~• jj~. ~Q~TYRi (Dr/ttt0+fi•1t) 22D. AOURESS 22[. DATE51GIk'D
to
~o.pl.e. • H.B.Goo J M.D. Fort Pierce Fla. 8-17-b4
~ , tlC~~tt~. ~ ~~T~ ~ j}~. NAMEOFGEMETERYORCREMAT0~1T 23J. LOCATqN(GY/,lMCw.e~tor~t!/) ~
rti.oviu (sped/yl .
Hillcreat Mem, Gardens Ft. Pierce, Fla.
Y. a. /e19 j~. F11MEIlAL O~~[ Oi1'S SIfd1ATUR[ ADDAESS 2S. DATF 11Et0. 6Y IQCAt REG. 2~• RE615TR1111'S 5~6NATURE
"...1°se Jose h W. ~ates Ft. Pierce Fla. 8-18-60 ~nna Lee Denisor~ d.r.
_ . . , .
- ~ I hi~rel~y, oaf't14Y /~~s-to be a true aRd correct oopy of the loca: " -
,~~tegis~tsrs ;etord'o~ #ik in tfia St. lueit County He~lth ~epart- G ~ ~ r
, -.rr~eM'~ t F
o~ i. P t e roal'.~tortda. E~ C~ ~ p#~1
='.~k ~ i~d unless raisad se,l ~f the St, lucie 3
- ~ ~ ~ (Werningc ~qt ~
,'=f--_ CountX ~Flaahh Department is sffix~d.) r ~,nD
_ i ` ~ ' _ c O C7 c_.- Cli ~j
- : ' • ~ ~ . : ; , N. D. MILI~R, M. D. ~ m F" k
, Gwnry Health Officer ~ locat Regt3trot ,o c~ ~ f+7 '
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~ p~ . - . D~epufy Local Reyiatrar ~ ~ m %
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