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' rh~s D~- 9TAT[ BOAAD o~ H~,~.rH .CERTiFICATE OF DEATH ~~~~~?'~'r"
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BURCAU OF VITAL iTATtYY1Ce F I.O A I D A $TATt FIL[ NO. ~
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ord rh~n g~RTH NO. R[G 6T A•6 O.
prop~~ly ruC[ 0~ D~ATN CODfi MO. 2. Y4UAL Rtt10iNC[(I/bn/rrwtH.J. II{VITrtYf: Ra{/~IIMwry~M{N{q~
~i~cut~d ~ ~~hTM a STATF D. ~OUNTY
°"j " St. Iucia
D• pl~e~d •
~p p~T_ p. CITY. TOWN,OR IACA t. IS /LACE pF OEATN t. CITY, TOMII,OR LOCATpN e. DS RFSIp[MCE `
¦~n~nL INSIpE CITY IIMIT51 IMSIDE CITY LIMITST
C31~. YES Iq? YES MO ~
, NAM (//qp~ h1 ?p~pktl, (bt ~httt ~!l?Lir) ST1lEET ADDltESS
HOStiTAI OA
1ltSTITUT WN
3. NAMt O~ Fli~t NtSIJt Laal Dl1TE Mo+~!)i D~y Ytb
(~7yPt o
=Prf~f) DEJITH
- S. SEX 6. OOI.OR OI! RACE MARRtED ~ KfYEII MARRIED? ~TE OF !lR7H 9. AGE (l~ /tnf ~?~R ~ Y~ tHCJEIl2~
fw~ DbtA~e~) XaW D~rs Rwn Xi~.
X r 1 t~ YYf00WEDO dYORCED
~ p 1 a 1 al y IOs. USU~L OCCUPATqN (Ofx i1RI oJrm! laxr IO~J. KI!IDOI~ WSIMfSSOR IMDIJSTRY I1. ~111 N?LA (~~tt or /orri/w to~Rlr/) 1. G7fzEM OF wrMT OaAiiRr~ .
r i t h y~ r- rrrts~ a~ort oJ ~att~/ liJe, evs~ 1f tftUN1 .
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Dl~olc ink ~3. fATMEl1'S NAME 11. M07HER'S AIOEN li11KE
or -
t~p~~~ittr
iS. WAS DECEASfD EYEI! IN U. S. ARMEO FORCESf !6. 54CUL StCURITT !q. Il. IM?ORM 1 HYifATYR[
(Y«. w~. rit,.s~wl (Il »r.1~M w w/+W d r+iiol ~i0 ril]_ B. Conover
A~LrtN
Funoral I6. CANf[ OI OiATN [Esler s+~ll snt CsrN psrlfw Jer U), (D). e~! (c).) i1(TE1lYlll 6E7~'EEN -
~ di~~tto~ ~ARTI.OEATHMASCAVSEQ~Y:
.u.: n~. IMMEOIATI CAlJSE ~ocardial Infarction due to Corona ~cclusion ~~rnmediate
ee. e.r-
cirie,e. cbndute~,.i/•¦r. ax ro ca) .
:len th. ~r~~c~ ~s,e r111~~~ r~ ~
1 o e• l ~tr~ G1t r~4r. I' ~ ~
r~~i~trar l?i~/ t~r~s ful. DuE TO (c) ~
• f t r 1 n 79 ~ M11T II. OT1E71 SaGmIICAxi Cp~Wi~O~E C,qfIMMliv+6 TO DE~?Tll Wi MOt RIIAT[D 1D Tlri iEltywrll D~5[AR CO~~T~OM 6~M rJ ?Ai1T f(a) . AS UTO!'ST
hour~ ~f- M! 6 .
~ ; ~ / ~ ~,?ERFOtMEDt
t~~ AeatA yE3~ jq~
er e. ror• i ~x~~~ ~y ~WURr ocr:RREO. (liktn w~twr yl~cr~ f+~ Pa! !K PsK 1I v/itrw !I~ ~
¦at1a~ an~ ~ Au~DENr wK~DE HCMKfoE - : G_'
d1~po~1- ? ? ? - . -
tion J p~. TIME Of HOU? Me~N, Ds), Yta . ' s: =
De4~. S 2De ~tuuRr s. -
S i. n. . r.
= 20t. IttJURY OCCtJRRED IDr. ?LACE OF IfUU11Y (t. f~ a~ort ?esu, tOJ. CITIf. TOYYM. 011 LOGTqM , ~•.OOUNfY STATE ~
WNLLE AT ~ NOT MfM~E ~ k?~~,i+~or~, ~lrtef. o~[ce aH., aa.) • ~ ! : i ~ . .
~ WORK AT WORK -
=~-l~tf~nd~dth~dee++~+dltom CC• f .to CC• „L andh~tuwh~m~lirson C•
drafA oeeurnd ~t 9~~l P~ m on tM d~t~ W fod sbo~r, ~nd fo tM bsat of m~ knowl~d/~, from fh~ uuMa ~tabd.
~11 1t~r• jj,~. s1YMATYR[ (Dt~?CtNfVG) 2?b. ADDqE55 =2t. ~ATEStGMED
ar• to tr•
oo~plsts • Bernard D. Rosa,M.D. Port SL. Lucie Shopging Ctr. 12/28/65
•OOU~\t~. ~ ~~,~~ATqN. 23A. Dl1TE 23c. /UMEOFCEMETfRYOlICRFNAT014Y 23f.lOGTqM(Cifl.~~.a+~~/) -
'~"~`e~s~`v~. 12-25-65 Rose Hill Cemetery banon ( Warren Co. ) Ohio
T. 8. /d i? FUMi1U1 ~ '3 SMrNATURE pRE • • 25. OATE RECD. iY LOCAL REA. REGiSTMII'S SKNATI7RE
a...lsae Milton W. Baird FT.PIERCE,FI.A. 12-29-b5 Anna Lee Denfson, d.r.
- -
, 2,
, : }
hereby c~ertify t~?is to be a true and corrict wpY of tha l«a= AN E C R D E D
Re~ist~er's record-oi~ fib•in tfie St. lucie County He,ith ~epart- ~~~I~Ia~~~~~a 0 0 K
~ . ~ rrieM at fort~ Pierce, ~fiorida. •
~ .
(Warning:Not val3d uniess raised ac~f cf the St. lucie _~~;~..-~CCi
• County 1~leehh Department is 3ffixed.) ~66 JAt, 2 7 ~M 0~
- = ~ ~ ' N. 0. MILLER, M. O. ~~~G+3~v
. . , ; ,
County Health Officer b local Stapistror R 0 G E R i' R:: S, C LE RK
- - . - i • . ST. L.UCiE COUNTY.
- -
1.
~~eSQ.aZ~ ~si=~a~.. 3r~. ~ F L 0 R t D A _
- - pat~ ~ ~ Deputy laxal RoQistrar d . - . ?
j - 800K~~~ ~ ~50 _ ' ~