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HomeMy WebLinkAbout1098 7Ais Da- HTA7E BOARD OF NEALTH CERTtFICAT~ O~ DEATi-! i E~~~~`/ 1 l~d ~ coaes • BUA6AU OF VITAL BTATI8TIC8 8TA7E FILS KO. legel ra~- FLORIDI~ ord ~Aen g~RTH NO. REGISTRAR•3 NO. 23 preperly 2. UfUAL REtID[NCi 1?li~t+or.atl:+.t !/:..c:he,.s: Rr:1we.?tf.r.si..:u:e. eilC~lted ~~AC[ OI DUTN GODE tQO. ~ STATE ( O. COUNTY ' end r111 a• rouNTY Ds plscad F • `ZC Sn pit- D. C1TY.TOWN,ORLOCATqN t.15 PLAC£ OF DEATM c-C~TY.TOWM,OR LACATiOM t. IS RESiCENCE ¦~rtlnt IhSIDf CITY UY1T57 II.S!DE tITY LIMITS7 f l l e. YES M7 ? • YE5 NO d. N~ME OF (//npt in ?ayila7, ~irc +lrtcl adQrru) ~ d. STREET ADORESS HOSPITAL OR ~ INSTITUTION 3. NAM[ O/ Furt lViCdlt Lart I. OATE Moall Da~ Yt¢? DiCUt[D D"°r~ RUSSELL DtJ:ir~~~J POORE 0E1TH January 12 19b6 S. SEX 6. COIOR OR RnCE 7. KApp~fO ~ NEVER MARR~FD? S. a7E QF E~R7N 9. AGE (!a /rsrt ~~R ~ Y~ ~ u!aDCn 2~ NK- !ti! Difl~Qt~) X~.t+a dw Hwn Xi+, ~ r r~ c. male whitE mooweo? avo+ecao A rll 2 1 10 pl~inlr ~~p, USUAIOCN?ATqH(O~itlin~OJrO~!lOAt 1~D.KINDOFBUSIIiES50R1110USTNY I1. liATHPUCf (S7~[[0l~O/tI0'~C09tiU/) IZ. C(iIIF.Y0fIf114TCOU.Yi~Yi •itT~ p~r- CurinOa+a[oJ~oatia/l~fr,raw(frlfvrd) aanent Salesman ~rniture Co. South Carolina USA Dlaclc 1nk ~3. FATkER'S NAYE 14- dOTHEA'S MR~DEM 1u1rE ~~P••~~~•* Geor e Poore Beulah k'illiams ~ IS~ WAS pECEASEO EYER iN U- 5. ARFlEO ~ORCEST 16. SOCUL SEfURiTY NO_ 17- IMfORIt i f~l4i'1ATt1R[ r.~.$ ~ ~$$CZZ D. Poore (Yr. v. r r3tw~ l!1 M~. I~w vw ~ ive~ d wr~+a1 Yes lr; W#2 2 1-40-9 83 1601 Geor ia Ave.-Ft. ierce,~ a. Pun~r ~1 l0. CAUf[ O! CiATM [Bwlt? onll ~wt ttru pt~ liws jor (D). axl (~).J INTEAYAI 6ETWfEN d 1 r~ e t o? ?ART L OfATN WAS CAiJSEC 6Y: deS~FT AND a TM IMMEDUTE CAUSf Probable Acute t~:vocardial infarct. lmr~e . ¦ust fll• se. c.r- . tffieat• Condiltoru,7Ja~?. p~E 70 (D) - ¦ith th• uA(tA pur ?ias (o ' 1 o c s 1 oDoet enwe ~ - itolia0 As nRl~r- .c • , r~alste~r :/in/ raurr fa~. ~++E TO (c) ' e f t n f n 71 0 ?AR4 Il OT~ S+ownCAar Ca+atqrb Ca+7wevi~•eG ra Ourw svt nor !t[uT[c ro THE TUtwwLL D~SFASF Co~Ci~ Grta a~ /Wxl(al'.. • . w~s OPSY. ~ hour• af- ~ = . TfRFORJitDt. - t~r d~stA 3 - YF50.lA~~ . Ot D~ f0?• 4, l ?pp. pES~RISE HOW 1lUURY OCCVAAFD. (EwlO attet7~ ~/ft~(ft/y i1 Pbt JOI P` ,.0~~(~ !~J ~ ¦~kfa; •n7 ~ ACC~DEMT SUiCIDE NOY1tl0E - - - ~ disposl- u ~ ? ? ' -i ~ - tlon Of J TIME Of Honr \(on11, D~i. Yav ~ ~ ` ~ _ . Dod~. u ItUURr a. a. - , - . ~ y. a. ~ 20d. IIUURY OCCURRED ~t. PUCE OF IMJURY (t. ix w aSOt+.! ~ost. 20f. GTY. TOWK.OR IDUITpM COUNTT STATE wNLL.c ~ ?aT wHi~E a J~°~./ana~. u.rB, oDtu Gt1.. dcJ - WORK ~T WORK ' ' 21. l~tt~nd~d th~d~ca~a~d/~om . to snd/~stu~ Aim ~!i?~on D~~th occurrsd ~t 2 P m on th~ d~t~ atrt~d ~bor+; and to th~ but ol m~ 1cno+~~sd/e, (rom th~ uus~~ st~[ed. •11 f c.¦. uo. s~cruTURC (nr,r« w rvk) tze. ~o~aess Z?r. oAh s~Lnco ar• to D• ~o.vloe. k ;•;elvin tiblko«sky,.i.D. 802 ?:o. 7~h. St.,Ft.Pierce 18 66 aeeu~~t~. ~ 8~~~~~ATqK. 23b.0ATE 23C.NA11EOfCfMETERYORC(iEYATORY 23d.LOC~TqN(GSf~,laex.~rcorat/) (sal~) R[rqy~l Sytti/~1 Burzaf t/15/fab Hillcrest ~:zmorial Gardcn F`t. Pierce, 'r'lorida , . Y. S. f 819 j4. fUMERAI DIRE OR'S SIGXATURf `j' ~ E j~~ Pti. ~.S' - O~TE REC0. iY LOCAL REC. 26• RfG15TMR'S SS6IUTURf a...1966 Jack J. Moore Ft.°ierce,Florida 1-19-66 Anna Lee Dznison, d.r. . ; - : ~ F~~ ANG RECORDED ~ ~ . . ~ ' : . , I _ R 0 0 K ; a~l hereby-teriify this to be a true and corract copy of the l«a. E Rergisf~ars record o~ fite in the St. lucie County He:~ith Gepart- : mant at fort PiQrce. -ftorida. ~66 JAN Z I PM ~2 Q ~ _ _ (Vl/aming: Nof valid unless raised se~f ~f the St. Lucie _ ' ~ Covnty I~aNh Deaartrtent ~s 3ffixed.) _ `~~rc~~l1_ ` ~ ' ~ ~ ; ~ . , RO~~Et~ Fii~i"R.{S. C~ERK ~ ' N. tiniu~R, r~. ST. LUCIE COUNTY, ~ • : : " " ' ~ ~ . ' County Nealth Officer ~ Local Registrar FLORIDA ~ ~ r , ' ~ , ° , Q ~p (r ~ ~ t~ _ Lti~ 4' R. ? ~ ~~J~..- - Dats DeP~1y Local Registrar . - ' 3C~K~36 4~3 ~ s i - -