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HomeMy WebLinkAbout1910 it~ls be- BTAT[ 80ARD OF HEALT}~ • CERT'(~'t~~?YE OF' DEAT~-4 ~ f~'~'~j! ji.~ ~ coaes a BURiAU OF VIYAL STATIG7'1C• STATS FILE NO. l~s~l feC- FLORIDA ord ¦ran BIRTH NO. REGISTRAR•9 NO. piops~ly 2. UtVAL RitID[NCt f?~r~fmu~/ti~e(. Ili~uliht~sw: Rail~ws~Ww~~d~iuisw e:eeutad ~u?C[ Oi O~~TM GODC NO. ~ ~ •nd sill ~~NTM e. STATf D. tOUNTY b• pl~c~d ~ . f n per- D. C~TY. TOWN.OR LOUTp c. ~5 PLACE OF OEATH c. GTY, TOWN, OR LOCATION IS RESIOEhCE ¦an~nt IMSIDE CITY IIMiT51 INSID£ CITY LIMITST tll~. YES NO? YES~ WO NxME OF ((Jpp~ M~atpifol, /stt ifrttt alliua) d. STREET A~DRE55 MOSt~TAI OR INSTITU71pN ~ 3. NAR7t O? Firtl AfJadlt Lut DATE MoaU Da) Ytar DECUf[D ~ ~'ti'a D''A'~ Jessie Mae Henderson °~"T" Dece~ber 27 j 965 , S. SEX 6. COIOR OR RACE MARRIEO ~ MfYER VARRIED? 8' ~TE OF l10.TH 9. AGE (la ~rai ~~R ~ Y~ I~DER21 HRS- . . laa~ OLtAdel) llnc?. D.~s N~.. Xt+, • ~ 1 t. Female Ne r0 +r~ooweo ? DIVORCED Jurie 17 1905 60 " p l ei n l y ~UAL OCCUPATION (QiK klAa 0J~001k IOrt IO6. KIND OF BUSIXESSOR INOUSTRY I1. BiRTHPLACE (57o1r w/orrl~w fwi~try) 12. pTIZEi10F wHAT 001Jh7AYt , ~ith p~r- Iurlepmo~lo/~oallA/JiJe,em~~tJr~(trrl) : ¦•~•ps House Wife Domestic Geor ia U.S.A. . Dl~ek ipk ~3. FATMER'S NA?cE 11. MOiHER'S MAIDEN ?uME ~ or t~p~rHt~r E.Z. Chazle StC11A O~Neal - 15. WAS PECEASEO EVFR iN U. S. ARMED FORCE51 16. SOCIAL SECURITY IiO. I7. INf01tMA i SIii16ATUR[ Oliver Hendcrson IYN. +N. r rulv..l U! M+. P+w wr w iUN N wn».) ~ Ho None Adu«~ 515 N. 11t . ree . ierce, a. ~ PbR~lil 18• 6AUti 0/ O[ATM [b'A/t? onll o~u uust ptt liru Jor (o), (D), ~n/ (t).] IKTERYAL EETWEEN dSr~cto~ ~~pTL DEATHWASCAVSEO~Y: ANODEATl1 . ~ ¦u~t fll• IMIIEDIATE CAUSf Cereoral thronbosis ~~a S eee e.r- - c~r~~.t. c,Aa;,r,,,,.+~.,,,, a,E ro ce~___Ny~_ertensive Cardiovaseular Dis. '~rs. ~ •itd tr• Y4ic4 pars r to - • 1 o e ~ ] aba: tauu~~). ' ' ti ~ • • ti r• istr~r ~latia~ Ut r~c4r. ~ "T: ~'l.~ : . a lfIRO «u~s 1u1. a1E TO c) • ¦ 1 t!f f n 7Z p ~ART II. 01?ER S~CMfKANT CWtOtT10h5 CprtltlitJTtNG ~O OEAiH CUT NOT REUiLD TO Tlti TFxYUMI dSUSt GOM~ITqN GiYEM {N T ICal•• s;; i_, A$ ~tfiOfSY . ~OLL~• at- f„ _ - ~ FrER~QAMEDr- • °.X , ~~s~~oT']= e.r d..cn ~ Previous Ceraoral thrombosis Iliabetes I~.ellit~us j' , or b~fots ~~.l ~ jp~.pEKR16EHOWINlURYOtCURREO. (EnlttRO~4~toJlwftt~/ixPa/l!'Of'.Pis?~'ll , li.)~.<*-~~~:--.~-='. ~ ¦ak~aa •a] ~ ACCtO[MT SUICIDE HOMiCIDE . ~ ' - •~po~!- t~ ? ~ ~ " _ "i _4. ~ Dod7. ~r ~ TIME OF Hour Mont~, Da/. Ye~r ' _ . . " { iKJURY w. 'z'_y.~,_~;.! ~ - e f. w. - • g 20d. INJURY OCW RREO aDt. ~UCE OF INJURY (t. I~t Cr ctax! ~o~r.s. 20J. C~TY. TOWM, OA LOUTqX ;"~~OQU _ ~ STATE , , WNiLE AT ~ tqT WHkLE ~ /~~./aaar.,~~arr, o~tu uap., ac.) - ' ~ ' ~ - ` WORK AT WOAK " ' 2~•lett~ndedth~da~uadlrom ~9 'Z _,to ~9 5 andl~ataa~?ti~~•lir~oo t Death oecurt?d ~t ~ ~ = A m on th~ d~ts ~t~tsd ~bor~; and fo th~ b~a! o/ m~ knowl~dp~. Jrom th~ uur~a ~t~t~d_ A11 1 t~ f s s10NATYRt (Dtpt~~ or Nfk) 22D. ADDRE55 71t. DATE SfGMEO - ~ b• 8p2 No. 7th. St. Ft. Ficrce 12/28/bs ~ eoaplet• I~:elyin Woll,~owsk ~2~:,D, s # aCeurato. BL7aAl.CRErATpit, 23D. DATE tk. NAMEOFCEMETERYORCREMATORY 23Q. LOCATqN(Cil~,[wcw.aewnl~) ~ F ~ ~`"°'~emo"~ 12-30-65 Levie Hill Cematery Warmspring, ~:eriweather, V. 8. #619 j~. FUKEAAL OIRE OR'S SlfilIATURE O R OS • 25. OATE RECD. BY LOCAL REG. ~6. RECISTRAR'S SwMATURE ~ a...i986 A.T. Stone, Fort ?i.erce,Fla. 12-29-65 Anna Lee Denison, d.r. - ~ - ; , :c ( - - _ # ''I .t~ereby'certify tfiis to be a true and corract copy of the lxa: ~ • •-~R istror`s recerd oh file in tfie St. Lucie County He<ilth ~epart- Fl~j~a~j~[~ REC ROED ± ~ rr~M ~t Fori:~Pierta,_~Florida. It1_~jfto~8( K~ i ~ ~ - - OK # (Warning:7Jot v~lid unless rais~d sc,l the St. lucie ` - : . . County. {-~ealth De~ariment is 3ffixed.) , ~ . ~ ,L~ ~ . . . ` - . 66 FE~ 9 PM Z : 58 . ? ~ ~ N. D. MILL~R, M. ~ : County Health 4fficer d~ Local Registrar ~G~).~~'~ ~ ROGER F-(1~Tr~;~~. CLERK . _ = ~-a- ~ T LUGIE COUNTY, ` ~ ~ ~l ,o't. ' ~D ~ _ Date Depuly Loca) Registrar d r,FLORIDA i 0 R ~ eoo~ 13~ ~.04 ~