HomeMy WebLinkAbout0065 >
reis bc- BTATE BOARD op HQALTH CERTIFICATE O~ DEATH if~ s r
eoaea • II `t~ ~Oll
BURtAU OF VIYAL YTATICT7C0 fiTAT6 F16C N6. ~
leaal ~a~- FLORIDA
ord ¦hen BtRTH NO. RE6IBTRAR•8 NO. ~L
pi'Operlr 2. UfUAL R[fID[NC[ !°?~.st~~/l:K1. !/i+~titrew: E~i~waWw~4~i~w)
e:~cuted ?UC[ OF D[ATN COD~ NJ. (
~nd rill e. COUNTY s. STATE A. COUNTY
~,,o=e, St. Lucie bb-02 Elorida St. Lucie
ln psT- D. CITY. TOWN.OR LOCATpX t. IS PIACE OF GEATH t. CITY. TOWN, OR LOtAT10N t. i5 nE510ENCf ,
t~n~p~ INSIDE CITY LI41TSi IMSIDE CITY lIM1T51 .
tii9. r'~`t.. P].cT'Ct YES~ ?a? Ft. PierCe YES? ?a
d. HAME OF (/f qp~ ~?p~pflcl, /itt ~trtt! sCQ~tu) d. STREET ADDRE:S Santa Barbara ~1VC .
HOSi1TAL OR
~hsY~T~TaH piercc taem. Hos . Rt . 2 Box 2 b L~akeV:ood Park
3. NAM[ OI Fl/If Alf~dt LaJI UATE RlOafA De7 Y~n~ ~
i~a
o
p•+~n LELAND F. BALL OfATH JSTIUB.T`V 13, ~ 966
5. SEX 6. COIOR OR MCE MARRtED {p~ MEYER MARAiEO ? 8~ OATE OF BIRTH 9. AGE l~a?~ ~ aocrt i rwe U~DE~ t~ ~S. :
June 9, 1893 ,~,~~`u~,~ ,..,w D.,. K..r. x~,. .
M r 1 t• M W Y/1ppWE0? Di4'OfiCEO
p 1 ainl ~ ~po, USUAI OCCUPATIOM (Q!~[ tiad oJ~co~t [oat 1W. KINDOf 6US~NESSOti INDUSTRY 11. BtATHYLACE ($(olt o?/o7ttpn tOtinhl) 12. aTi2EY Of Mxli WuNTRri
~Str p~r- Ourinpuiioito/iro~tf~/l~Jr,newlJrrftrt()
Fitchbur 2~tass. USA
Dl~Gk 1pk ~3. FATHEN'S NANE 14. MOTlfER'S MAIOEN NAME
or
syp..r~c.~ . Fdith Dix -
1S. 1YAS 0£CEASEO CVER IN U. S. ARMEU fORC[51 16. SOCIAL SFCURITY MO. 17. IN/ORM ~ N4MATYRi pauline F. Dd.ll
. I Y11. M. M r~Y~1 ?a. Iiw w r Mtn ~l .~~a)
01 -0- 2 0 ~+dar~•, Ft. piercc Flori a
Fun~ral 10. CAVS[ 0I O[ATH (Sxtrr o~al/ ont cawt pt?li~ct~? (a). (6). aaf (t).J . IMTERVALlETWEf11
?ANT 1. OEATN WAS CAUSEO !Y: ~ Qrf$F,T A1~D DEATH
a,r.~co~ emorrha e ~
~ 1?iwEOI~TE CAUSE ~ ~
¦u~t flle .
t6• e~r- i
ti[ie~t• Conduto+u.f/QnI. puE TO (D) • . ~ . .
Sl.S '.~snl%
~StA tLs ~elic? yue ru~nto . ,
l o e~ 1 obort cauu . ~ ' .
f• 1stTar +ta[in/ l#t rnGr. ~ - . • "
6 lriny tauu lat. ~E TO (t) ' ' ~ _ ^
~ • 1 t h 1 n 7 Z ~ /ART II. OTlEA SK Wi1CAtfT COttqTqN3 COHTIU~(1iLVG TO OEATN !lt'f M07 PMTED i0 Tx[ iUtY:tul GSEASE CW+'OIT~Oi~ GMN W.Pll~i . WAS ~
hOUr• al- F - , ' ' ?FRFdRM T_
t~e ds~tb s - .
YES ti0
or bafor• ~ ,
20a. < <Q 20D. DESCR~BE HOMf iNJURY OCCUAKED. (E~ft? ttalu~t OJ(nfW/ fq Pa~t !w PplH, OJkt+4~~J'.': ~
¦~tloa anT ~ ACCiOEItT SUICIDf MOi1lCIOE
dl~po~f- ~ ? ? ? _ .
tion o[ .i, . _ . -
~ 20e. T~wE OF Norr J~loatl. I?a~. Year • '
bod IN.IUAY w. ~ . . ~ ~ ~
p p. a~.
g 2Q1. INJI'RY OCCURREO 20e. ?UCE OF IHJUAY (t. tn ci aDou1 Aonu,~ 2% CtTY. TOwN. OR lOG1Tq?~ OOUNTY STATE .
MrHRE AT ~ ti0s wHn.E ~ /w~.l~orr. k~rd, oL'tcs bflo.. elc.) ~ .
. WORK AT WORK ~
21. /~ft~nd~Q eh~ d~uas~d /rom ~ Qb2 , to Dcath •ndlut s~w hi~ •li?~ on ~
Deith occurred at m on fhs d~b st~bd ~bor~; ~nd to th~ bsef o/ m~ kno+?l~d~e, from th~ uusei at~tsd.
AIl it~is - y~_ flCtulTYRi (DrqrnatllG) 22A. ADDnE55 72e. DA7ESIGttEO
•r• to D•
co~plet• s Dcnald R LaPlatne 610 N. 7th. St.,Ft,.Piarce 1/19/66
•tcu~ at~. ~~u. C1tEwATqt~ j3a, pATE 23c. HAME OF CEMETENY OR CREMATORY 23d. ~OCRTqX (G5f/, (otoa. N tof+nly)
REMwu l$D~[i1r1
Removal 1-1 -66 Paln Beach ~:em. Pk. Lantana. Florida
V. 9. ~611 j~, fUNFRAI DIRE OR'S SK.MATURE 00~ A~pFS~th • St. 2$- QATE RECD. BY LOCAL REG. ffi. REGISTRAA'S SIGMATURE
7
a...i9aa M:ilton ti~i. Baird F`t.Pierce,Fl.a. 1-20-66 Annn Lee Denison, d.r.
. _ . ..t:. , ,
, .
! hereb = oi ~~t+'s to be a true and correct copy of the loca: F~LJ ~D.R E C Q R D E D
y~f~ ~ ~ I N_. i.~1TICi8i KECCra 8 0 0 K
~ - Registrars ~record, on fik in the St. Lucie County Henltf? Qe art-
~ n~ent, qt foft PierCa, Florida. '
° ~ ~ arnin valid unles5 raised se~l tho St. Lucis =
~ ~ c~n~ty FieBhh Dep~rtment ~s affixed.) , .'66 ,~QN 2 S pM ~1 ; y g ~
~ .
; _ . . : _
~ ~ ~ . 1~230U
, . N. D. MILL~R, M. D. ROGER P .
' ' ~ : ; , County Health Officer ~ local Registrar T fZ~S. CLERK ~ ~
- . ~ ST. LUCIE COUNTY, ~
F _4 a \ l~ ~ , ; FLORIDA
. - ~~'~.':.ib ~iDf~ ~ g iR'~,~
p~b ~s pepufy Local Registrar •
C'~ • r .
~ BOOK~J~ ;W: -
_ - - -