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IN RE: HARRY WTLKIE TAYLOR~•'~•f: ROGEr< f'0;~1~f;.,S, ~I~ERK
• ST. LUCiE COUNTY,
FLORIDA
. . . - ~F CER ?1FICA i ~ OF DEATH
~ • i: _ ~F ~lT.'.L °Tlr~e~4~e sZ.\7e F~Le No. -
,:r,: .;~en FLORIDA , _I
. ..1~ '~E;IRT'r{.=NU_ REGISTRAR'S ti0._ -
.~~ecuted I. PLACE OF DEA7H ~CODE NO. ~ 2. USUAI. RESIDENCE 1~~~~c~zecea:Nliral It~~~tt~utcce:rci~d<:-:~t.:.:e
a~_r_ I.~::L l.
~ ~r.a .il l COUNTY ~i a. STATE , b. COUNTY n~y-~uG~E----
pleced . T` .
in par- ; b. CITY Ut a~u~~i~ com:r.t• tim~a, ,rdce xou.~1.1 c. LENGIH OF c. CI1Y ltt oui~fd~ cuv:nu I~otU, rrit~ &tiRA41
¦snent OR STAYUaue~c~.u) ~ OR
fi1e. T04IN F~~ pi [3rnP , ~ TOWN ~
' d. FULL NAME OF 11( r.~t In tuwlW or Irutitu~lm, ~1~~ ~trest ~d..r~u ~r lacstlon) ~ d. STREET llt n+r~l, el¦~ laetlool
~I HOSPITAL OR ADDR:SS
~ INSTITUTION i O~_.Z_~~~ - .
3. NAME OF (First) b. (Middk) e. (La~t) 4. DATE (Dfontb) (Day) (Yr~r) °
DcCEASED ~ ~F ~ ~
~ (Tyye or Prinel ' A" DEATH tj],~T29-~.qr-~._- ~
~ 5. SEX i. COLOR OR RACE MARRIED, NEVER MARRIED, t. ~ATE OF BIRTH 9. AGE~~~ ~exr 1! Y~il~ 1 Ti~t' 11 O~D(~ ll M~f 2
WIDOWED, DIYOACED ~SaK~h> b.t ofnw~» ~ta.ti~ vaJS~xoa:r. ]ttb '
~ t?alo 1rlhite i~:a„ri d ~ept. 2$, 188~ 'j0 1.0~ 11~__ ~
~tn1y Ii~D~. USUALOCCUPATION~61.~ klnd o[ v«) IOb. KIND OF SUSINESS OR IN• il. 61RTHPLACE ~ei.e~ « toreiao countn) 12. CITI2EV OF WHAT
~ith ner- 11 . I -
~d.-,.-.ac~rir.- aa:ci~=i:xci'sE52,'r:c33a.r:~; >:;s:.°.v [:AIIN Q _
. aenent T..Y1
Dlec4• ink Sa~.~esna.n ( Auto ~ Cor~ica, Pa. I Us~
or ~3. F/1iHEA'S NAME 1~. MOTHER'S MAIDEN NAME
i
' t)Ferritcr ~iarr ~la ~ ~
1IS. WAS OECE/1SED YEA I!. V. S. ARAIED FORCES7 16. SOCIAI SECURITY 17. INFOAMANT'S 516NATUAE rlZ 1~On i'I. Eai rd
; I` lYe~. m. or mtr.ovn) lit 1~~. t1n rv ot d~u~ of ~tnln) NO.
~ Q ~oaRSSS , !
tunersl ' 11. CAVSE OP DEniH MEDICA~ CERTIFIC/1710N IXTERVAL 6EYNIEEfi ~
d~raccor ~ Eutcr onh one esu~e OISEASE OR CONDITION ONSEY AND os~t» ~
~ust filc ' 7~r line for (n), (D), ~~RECTLY IEADIN6 i0 OEATH'~s~ ~ - '
cnc cer- ~ +nd (c) %
citicnte ANTECEDENT CAUSES ~
t t. t ~ r I •Ti.ii dota no! ntan DUE TO (b
I o ~ r 1 ~!ht ar.ode of dyinp. ~orbid tondition~, i1 aaY. Diviny .
j, ~uc7. sa Acert lailrre, ri~s to tA~ a6ors cawe (a! ~Wt-
~ rc;,.+tr~r aatksnin. rte. !t ntans i„p tJtt wnd~~lyinp tatii~ Ic~t. .
•lcnir. 72 th.s dis~ass, injtiry, or DUE TO c
;~r c~rnyliration w A i e A OTHEiI SI6NIFICANT CONDITlONS
• ~ - de~tA i~aY~ed dcatll. Cosditimu contriGutiny lo tAr denfA bYt not
~ ~ore ~ sel~tsd fo tAe dis~a~e or condition caYrin deatA.
=~„ing An~ ( 19a. DATE OF O?EitA- 14D. 1~lAJOR FItIDINGS OF OPERA710N 7J. AUTOFSY?
: •.;.oal- ( TIOH
. OC ' YE~ ~ t~i0 ~ ~
'j ~~Ya•~pu~ levKu~) 21b. PIACE OF INJURY (~.~..iuozsbx,i ]~t- (Ct7YOATOY/N (COUNTT) (SUTE) ?
i `~y ~ ~j 21a. weeioeH7 eom., t.rm, t~ceor~. «rese, d1n EMS.. sse) It ruaL ~eau SUR~L~
i j~ suic~oe
~~o~l
, ' 21d. TIME (~toe~D) lua~) 1Y+~r1 IHoa) 21~. INJURY OCCUR0.ED 2~ . HOW OID INJURY OCCUR?
i~ OF waitt~T roirNnt
~ INJURY d ro~[ ? ~t rotK ?
ij SC~ 1~T0 t ~ ' /j~~ I last aato the dcceased
~ i~ u. 1 hereby ccrli/y ti,at 1 attcnded the detease from 19---f
f./`r
,i i i cea. !i AjtL~e nn-.~~r'-f
f~-~ 19 and thal death occuned at rn. rom !he tavacs and on !he date alated nborc• ~
nra :o De 22i. SIGNATURE (DcQrN or tttle) • ~b. ADDRESS 2~c. DATc51GNED ;
coa~late ~ ;
~ . .:.rata. L.D.VanTilborg, i`fi.D. 101 Atlantic kve. Ft. - ~ _ _
~ !':;a. 6 U R 1 A L, CREMA- 14b. DATE 2Sc. NAME OF CEMETERY OR CREMATORY 24d. LOCATION (Ciqr, town, or county) (State) '
~ 7'ON, REMOVAI (S~alb) ~
; i~ 1_ Ft. rierce Cemetery Ft. Pierce, Fla.
? t DAtt kEC'D BY LOCA~ Rc615TfcAR'S 516t~iATURE 25. FUNEML CIRECTOA'S S16NATUflE ADDRESS t
: v.s.#ZOO ~i REG. L e enison s.r. I•':ilton ~~J. Eaird, Ft. Pierce }
!
1
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~ I; hereby,certify tfiis to be a true and correct copy of the loca:
Registra~'s• rec~rd on file in the St. lucie County He:~lth ~epart- ~
~ : rrse~t at ~orf Pierce, Florida. ;
l i . . . ' , •
~ _ '(V1/~miiig: Not valid unless raised s~~{ ~f tho St. Lucie i
l Co~nty. Fieahh Deaartmem is 3ffixedJ ~
~ ~ . ' . : , ~ . . r.
:^t ' N. D. MILI~R, M.
~ County Health ~fficer ~ Local Registrar
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~ ' '.~a ~E~ £~~.noS~u-- '
. „ - ~ . ~ •~afe DePuty local Registrar ~ . r . ~ i
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~ LAW OFPtCES
' WILLES, BITTAN 8~ GRIFFIN
~oQK~~~ ~a~ P. o:.oX ~ -
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IORT PItR6~~ FLORIDA