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 ~
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