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HomeMy WebLinkAbout0216 th~s De- ~ BTATE BOARD o~ N~?~„s CER7tFICATE OF DEATH ~q cotes s BUREAU OF YITAL 87AT167tC6 ~~3~s ~/6 lebal rec- FLORIDA ord ¦Aen 6IRTH NO. ' ~ REfi15TRAR'S NO. j prape~lr 2. UfUAI q[fIDENtE R' e=lCUted •UCE O/ DU7H CODE NO. ( Llrrl.taw:fl~~ (f~~~~lrf~~w~ RM~ACI~SMI~~u1ila) ~ and ¦111 ~UNTY STATE 1.. ~puNTY D• plae~d ' ^~1T1ti r+ ~@ f 1QY'lC~a ~ 171 psT- O. CITY. TOWH. QR LOCATqN IS PLACE OF DEATH C~TY. TOAfN, OR LOCATION t. IS RES~uE~CE ¦lq~nt 1H510F C7~IyTY LINITS? IHSlOE CiTY LIMIT51 ril.. Fort i e YES{pJ Kop Fort Pierce YES~ ?+o? I. NIIME OF (1/uol fw ?upilsl, ~is~ ~trttt aQdrru) LEIiGTH OF l. $TREET ADOflE55 HOSPITAL OR OH A fARMf ~rsr~TUraH 260g Avenue 'rFrr 5 Yl~z'S 2f~0 Ave. nFn YES? no? 3. ~tAM[ OF Fint ,Vfd/!s La~t OATE Mo-xtA Da1 Yur OEtUf[D OF ~'y'~°rDr'~~ Sarah Goff Foster ~TH Jan. 0 191~ S. SEX 6- COIOR OR RACf NAqR1ED ~ NEYER MARAIEO? e. DATE OF 91RTN 9. AGE (/a rtar~ tF UhOER 1 tEM ~f U~CER 21 WK. ~ lu! Di~lA6~)) XMty p~~ H~wa Xi+. r ~'emale ve ro Se t. 18 19 plllnly g WIDOK'ED? DIYORCED r~ ~h USUAI OCCU?ATqM (Qi!( kind oJm01! LO~t 10D. KINDOF BUSfYESSOR IHWSTRY I1. BIRTHVLACE (SYdt ar ~o~tpn t0urttrl) 1I. UTISE1t pF Nt4Af COUhTR1'I P lnsf~o stal o~atia~ f~Je, uvN tJrrlirrdl ••~•n~ ~~~aid Hotel i-.onticello Florida U,S.A. Olack !nk FATHSR'S M~ME IJ. NOTNEA'S MAIDEM NA7~E oi trP~rrit~r i•iay ~~lathis Sarah Harris IS. WAS DfCEASfD EVER IN U. 5. ARNEO fORCES~ 16. SOCUI SFCURITY HO. 17. INFORMAN i NGNATYN[ John Foster I Yr. u, r r~Fyrv {I/~e~. NY R/?41 ~I Mf+d) '~O ~+du~~~ 260 Avenue "F" Ft Fi r Fl Fun~l~l ~0. CAUt[ 0/ DtATM (Enfrr oaly oRt c~rrt pn iin~/nr (a), (0), anI (c).J INTEHYAL lETWEEN dl~~ttoi ~ApTL DEATMWASCAUSEOiY; ~ Ox5E7AMODUTH ¦ust ~ll• ~ INMEDIATE GUSE Carcino?atosis tA• ce~- tltieat• Conlifiow~,i/r~~, ppE TO (D) Carcanoma Breast rith tA• rlicA ou~ ritf h~ 1 o e• 1 ~Dxr cunu • r~afstr~r ~laliw~ (~c n~l[r• !/in/ castt 1a1. a+E TO {c) •itAin T1 = AOUf • a f- ~ ?AWT 11. OTI~J! SlGMlfIW(T Cpiqi~Otit CpHTRIBIJTttl. TO DEATM 6Vi iVOT REUiED TO TxF TERMt.~1Al DISfASE CORqTtON GtYEM t!1 ?aAi I(~) . WAS AUTOASY S P[RFOAME~01 t~r destA YES? NOU? or D~fore 4 •aYlas •n~ ACADENT SUICIDE HOMKIOE ~~R~BE IWW INJUAY OCCURRED. (F.nh? e6fur~ ofiwJrt~ i~ P~i~ /a Put 1I oJilaw /IJ ~isposi- u ? ? ? lon ot p~ TWE OF Horr Moata, D~~. Yrnr ood~. ~ ttUUnr o. a. o P• w ~ 20d. I.~UUAY OCCUAAED X1r. PLACE OF InJLRY (t. y., iA or aAOU! Aouu, 20J. CITY, TOWN. Olt LOCATION CWXTY STATE WHILE AT ~ NOT WMLLE ~ /um, /ulor~. Hritt. ojRlt A'f/., t(tJ ' ~ ~ WORK AT WOAK ~ ~ 2~~ l~tf~nd~d th~ dseeas~d /rom 197V , to J~1. ~ •ndfut s~w~ ~,m a/ir~ on J D~~th occuned~t 7%0~ P• m on ths d~te at~ted abor~: ~nd to fhs b~~t o/ my knos?l~d~~, lrom th~ uu~~s statsd. ~~1 lt~~s ~.fIC11ATYR[ •r• tQ D• (tltintortUk) 22D_ AODnE55 21t, OaTESiGNfO ~o.D~•c• • I•far~tin G. Gou1d,,K.D. Fort Pierce Fla. 30 Jan. 60 accu~ 4tr. ~~~4~, C~Ew~TiOrr. 238. pATE 23c. NAwE OF CEME7ERY OR CREMATORY 23d, Lp{,~TION (Ci(~, (prn, or Counlr) (Statr) RFMQY ($j![[I~/~ Buria"~. 2-7-60 Pine Grove Cemete Ft. Pierce Florida V. S. /E14 24. fUHERAL DIfiE OR ~S SIGNATIiRE AODRE55 25. pATE RECD. BY LOCAI tIEG. 26. 0.EGISTRAR'S SIGNATURE R~..1956 Bernard R. Gibsor~, Ft.Pierce 2-1-60 Anna Lee Denisvn ~d:r,,, - - - ~ . - • 1~.,. ,^'J ~ i~ f~' . • : ~ ; - + ~ . ~ i, ~ ~ 1 her~by ceriify this to be a true and carrect copy of the Loca: _ ` : Registrar's record on ~fik in th~ St. lucie County He,)th Dapart- - ' mant et Fort Pierce, ~ FlQrida. - = - , : - : . (Waming: Not~.velid unless raised se~f ~f tho St. lucie l,,,F~~ AN ~?ECQRD . ' County-Ftealth De~artment is affixed.) ~f~~ . . ~ ' _ ~ 1 ~ - ~ r ~a~OK~ . . . - . . • . . N. L~. MILL~R, M. ~6 <<~i'`' • : ' ~ ' ~ , _ County Health Officer ~ lxal Registro~ ~~N 2 8 pM 3 • . . , ~ f~,~ ~ . • zs _ ~ - ~ o -~D ~on t . i, ~ ` Dab Deputy local Registror S7'. A`~''F'+~ .C~ERK - RK ~ r~'7 ~ ~FIORIDquNTY, - QO . ~ J 1 ~ : ~ 4