HomeMy WebLinkAbout0904 Th~, D~- ~TAT[ BOARD o~ H~,?~,~,~ CERTIFICATG OF DEAT~i cd~ ~C ~
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r~~.. Ft. Pierce YES~p No? F P e „c,~ ,~,o?
MA4E OF ~yyJ~ ~~tut a/drt~~) LENGTH Of J. STREET ADDRESS
NOSl1TA~ pq ON A FARM)
STAY ~N ID YES ? !ip ?
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~ S. SE% 6. COIOR OA IIACE MAR111E64.1 NEVE0. MARRIED ? e. DATE Of ~1RTN 9. AGE (h /tarl ts I~+CEII 1 YEAk if Veit+ER 21 NRS.
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~ i t• Ma~e 4Jh~t.e w;00WED Q avoncco `.i t.. 1$ 80
yl ~1 a 1 y I~e- USU~I OCCUMTqM (Q{It t14Q0/r0/t [ORt 106. KINDOF ~USINFS501t iNpUSTqY 11. •IRTH%LACE (StKt p~0/tl/f tOYRt?~) 1. CIT1ID1 0? MfMi1T 0041!lTRYt ~
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D11Ck 1Rk ~j. FATXER'3 NAME I~- MoTNER'S Y?If1FM ulYt
~~?••ric.~ David Hansen Ta lor ~ Texana Russell ~
IS. wAS OfCEA5E0 EY[R IN U. A ARMEO FpRCEST 16. SOCIAI SIWRITY l80. 17. IMfORM i MOJIATURt J W yates
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MOAK AT MORK • "
Z~• 1 aff~nd~d fh~ d~u~s~d /tom 7~a.~71 , to l~`~1-rib •nd /a~t aaw n~~ •Jir~ on l`ZQ• K`~
him 5~
D~~th occurnd ~f ~ 7' 1(,L A, m on fhe d~t~ ~Nf~d ~6o~s; ind to th~ b~~t of mr kno~rl~d~~, from th~ uu~~~ at~f~d.
111 lt~~~ jj~. }I~MATYRL
•t• t0 E• (fl[i~ttorlUG) 22D. ADDRE55 72t, ~ATESIGNEO
~o.pi.c. • L.D. VanTilbor 1'.D. 101 Atlantic Ave.Ft.Yi F
~eeurat~. ~~u. ~~~T~ ~ p~TE 23C. NAME OF CEMETE0.Y OR CREMATORY 23/. LQCATpM (CY/, (p1Cff, p/ tpsiqt~) (SY~It)
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~urial~ 1-2 -1 6 Hill est k?emori 1 Ga d F Y'
. A. f 611 j4. ~~RAL DI E pA'S SK.MATUIIE AODRESS 25. DATE NECO. !Y LOCAL RE6. 26. REGISTIUiI'S SIGMAT RE -
~oaa Jose h W. Yates Ft. Pierce 1- - 6 A ~ r_
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~~,`;1 •~er~liy ~fy't#if~to be a true ~nd corract wpy of tha Loca:
~~~1~ ~t~eyi~trar~ returEt ~qn~#jb in the St. lucie County He ilth Oepart• F I L E D A N D R E C 0 R D E C
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~iNaminge~pt valid unlest raised se~I Ihe St. luc+e ~
~ ` _ : ; Counly: Health Department is ~ffixpd.) , _ ~
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• , : - :t, - . ~,6 J~;1 ! 7 p,~~ 2 . y6
- ; , N. D. MILI.R, M. d. •
;t t~ j~.~ :`\;~.County Health Officer d~ local Regi:tror 1-~ G~~`-rl
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" Data Deputy local Refl~strar FLORIDA
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