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HomeMy WebLinkAbout1085 r?,,~ De- BTATE 80ARD or Hr~?~~rx CERTI~ICATE OF DEATH ~ l~.~j f!?~ ~ ~..~_x..~ co~es • HURUU OF YITAL iTAYIOTtCY 6TATG F(Lt NO. legal rec- ~+~O~IDA , ord xhen A~pTH NO. R~f.16TRAR•e Ho. 433 proparlr eieeuted t. PLAC[ Ot OGTH CODH NO. 2. UtiJAI REf1DptC[(~?,...K.e.,tKo.l. f)t..e:nr~.w~ Rait.wW.n.A.L.;.,) •nd •ill ~U~n a. STATE COtlNTY Ds pl~e~d •St•• C.~C 66°~.Z r'~.0: 1~13 .St. C~C !n psT- D. CITY.TOWN.QR ATpM t. IS ?IACE OF OEATH t. CItY,TOWN,OR LOCATq,y t. IS RESIpENCE asnont IHSIDE CiTY LIM1T51 iN51D CITY LIw1i5t • fll~. P1CI'CC YEi~ rp? ~fC2'Cf; Yf~ t+o d. NAMF OF (/J~yp~ fe?GpileJ,liet ~trttt aQ(tu~) 1. STAEET ADDAESS HOSPiTAL OR 'NST1TtT1ONFt.pierce Mcmorial Hos ital 2J~11 Sunrise Blvd. 3. NAMC O~ /Yt~( A(!t{!t La~! OATE Moi¢tA De~ Ytat DtCGtID c~a o. p~r~r3 WI~pM CLARE~ICE BAGGETT o rH December 16, 1 q65 S. SEX 6_ COIOA OR RACE MA1tR1ED NEYER MAlIR1E0 DATE OF lIATM 9. AGE (/F ~tw! ~~~R ~ YGR ~rtpERi~ ~S. tut r~dol) X~wt4 D~a~ Hwa KC., r ~ i c. M81e WhitO wioowco ? avosceo ~`3y 1~~ 1893 ~ p1~llllr ~~p, USUALOCGUPATION(QittliR~o/~c0~~(oAt 10b.KIXDOFBUSINES50R:NDUSTNY 11. B~RTMPLACE(SYaftor~o~tl/qCp~Rl~/) 1. CITIiU10FMfHATCOtR(iRY! r1tA p~r- (a~in m oJroitf,~ol~/e,~m~IJ~fti~rl) eicr~c Circuit Court ( et. ) Tennessee USA Dl~elc Inlc )j. iA7HER'S NAME !1. MOTMER'S MAIDEN NAME t~p~sr~t~r Flfllism Het1Fy &3ggett Zilpha BIy8~it, 15. WAS OfCfASED EYfR ~N U. S. ARl1ED fORCE5/ Ib. SOCIAL SECURITY NO. IT. IN?ORMA { f10MATYR[ a ? $g~C f Yr. v. r+la~rRl U! K+. ~ir~ av ~r iWe e/ een:a) ATo 2b6-34-0023 ,cd~,«, ?1~11 Sunr ae v. . iei•ce, a. fun• ~ e~ 16. CwUft OI OiATN [Esk? owl~ oat c~uat yt~ li~r /Fir ~a>, ad ~r).~ it17[RYAt lETWEEN dl~ettOt I~tRTl. DEATHWASCAUSED~Y: O11~ AyO~~.~DfATH ¦u~t C11• ~MMfDlATE tAUSF Caronary Thrombosis 1~ rLUj~ tA• e~t- c:r~~.c. c,Aau~,,.r~.~.. ~,.o Coron Heart Disease _ Years .ien en. ~~r~a 4o.e ,r,~ ~o (a) 1 o e A 1 oDwe erwt . r~aistr~r ilolin~ l.lt ~xltr• , . ~s v ~ l~tn~ [~ru lat. WE TO (t) ~ ~ - •itAin ~9 ~ If ou r• • t- I'ART 11. OJHOI SK1~i1CA1(T COnp7ldd CprtlpStJTING TO DEAM EUT 110T REtAtED ro M[ TLRrt7?~?l pSGSE CCMDII'IOM GlVtlf i!1 ~ 1(~) WAS AUTOASY t" RFOR~E~1 c.~ a..ce ~ 01d Amputation Rt.lcg ~ • • ' ~ ~ or E~for• • ~ - ~ •ttEs(~ ~:o? mi~ ~ ~ ~Ib. DESCRIBE N01Y IMJURY OCCUARED. (Exln qefurt i( . tw Pvs I a PM 110 Il~p 1~_) , •aklna •nj ~ ACCIGFNt S:IKIDE HOM1GpF . / ~ 1 _ r.. ~ . ' Ql~poai- aWi ~ ~ ? . ` . : c• `s • . v: _ ~SOA OC ~ bodr. ~ 20c. TtwE oF Nos~ M~tA. D~f. Yto _ 1 r- : r nuuAY a, G n. w~. ~ C a• ~f'e - W ~ 20d. ~NJUR1/ OCCURREO 20r, tLACf OF ~rUURY (t. M a~Aou! Aon~s, 20J. C~TY. YpWN.OR LOGTpM 'pCt1A , - WMiLE AT Q HpT MfMtLE ~ ~~a.~~ol/, Hr[d.O1jI[tWl/., dt.) ~ ~ S~ vZ STATE ~ 1MORK AT WORK ~ ~ ' ' ~ 21 • / ~ttsndad th~ d~caa~~d (rom , fo r" ~ •nd /ut sas h,~ +ler~ on ' Daath xcurt~d ~t • fh~ d~t~ rat~d a6or~; ~nd to th~ b~~t of m~ kno~rl~d~~, /rom fh~ uu~aa rfet~d. ~ 111 lt~a• ~ fIGli11TUR~ - ~T• t0 0• ~DCCr~~alUlt) Z2D. ADDP.C55 22t, DATESIGNEO ~o,D~ -b. : A].fred J. Cornille, M. D. 03 Nibiscus Rd. 12-2J •CCU~at~. ~fMATpN. 23D. DATE 13t, NAMEOFCFMETERYORCRfwATOAY 23/. IpCATpM(Cil~,lO+cA.o/[ouA!/) (SYalt) "~~i~"h' 12/1g/65 Hillcrest Mcm. Gardens Ft. Pierce, Florida V. 9. f al7 j~_ Fi1NFRAL O~ E OR'S SIGNATUR 1L' ~ppS~ ' 23, wtTF RfC~1. SY 10.:~ P.fc, 2b. AEGtSTMR'S 51GMATURE a... ~flee Jack J. Moore, Ft. Pierce, Florida 12-za65 Anna Lea Denison, d, r. jti ~ , . , ' ~ FI~E ~,t~ I her,eby'c{ertify :this tp be a true and correct copy of the Loca: R~ C 0 Rp , FR'egfistTar's r~cotd on file in the St. lucie County Heitth Oepart- :i . - marrt ~~t'FBrt• Piesrae, F(orida. ` „ _ ~ 0 K . , • r _ ~ ~~?•4_~. i(Warning: Not valid unless raised se~( ~f the St. tucie ?~c ° County liealth Dapartment is 3ffix@d.) V 4~~~' 2~ Nl' ~Q : 33 ~ i ~ r. : • , ~ ~i ~ q f~ ; • , , . _ N. D. MILI~R, M. 3 ' ~ ; ~ ~ ~ -~3 • ROGt:{ c_J:- r -~.ti ~ • ~County Heaith Officer d~ locat R istrar L L~ ~ , , ~ sr. UCIc COU ~TY~K ' _i L`1~4~" ~ ~ ~tL~s , ~ sn~ F~ORlDQ. Dato Deputy local Registror d. r, ~ $OOK ~Ub ~~U . . . ~ ,