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CERTIFICArE OF DEATH ~
FIORl~A
K~ ~ IOCAI IK! N0.
~ OECEDEN~-?~ME FNtSt M~OOtE lwST SE% DATE Oi OfA7H(Yp.O~~. Y.~ -
Hary Katl.ryn Smith ?Female , March S 1985
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_ 6602 ~CE-~q. lNwt~. 04c~ AGE-1p18rtfW~Y Y~ R 1 YEAR UN~ER 1 OAY DATE OF 81RTHIMO.OsY. Y~ ~ COUHTYOF OEATN
Nn NC ISMC~h1 ~ 1 ~ pAys NOURS ~ YINS
.~te ~ x s Se tember 21 1926~, St. Lucie
CITV. TOWN Oii LOCATIQN OF DEATN tIG~SP~TAI OA OTHER INSTITU110N-- Wm~ Ill nol .n «~Mi. q~.~ stnH ~+d n~rmWr~ li MOSV pp INST ~IiWitN~ ppA,
„ Fort Pierce Lawnvood Medical Center ev Emer. R om r~~
STA7E OF B~RTHfl/~dr~ GITrZfNOF W?1AT COUNTRII MARNlED MEVER RMMtEO. SUfiVtYWG 5o'OVSEi/1~dR pMT~dMn~~1
7~ SA. carwrr~ w~00wED. WvORCEDtSWC.h)
~eorg~a , U.S.A. ,o i?~idowed „ None
SOCIAL SECUii1TY fNJ~EN USIML OGCtWAT10MlOp
t ~ort~^C•d1 ~~N~~
AIwW/ KItO OF BUSrNE55 OR IRbIJSTRY
252-36-5489 Clerk Store
REStOfNCE-STAIE COUMTV GITY, TOWT1 OR ~pGAT10N STREET ANp NlA1BER iNStOE GTV LIWiS ~
~ 1 lsr+uh vw o~ Nol
,w Florida St. Lucie ,k Fort Pierce ,w 3224 C. West Lake Dr. No '
_ FAT1$p-NM~Q fIR$T WOCIE LAST MOTHEP-MAIDENNAYE fiR$T YIDOI.E UST
,S John H. Burnette ,a Louise Hawkins
. piFQiYANT-NAYE ~T~ p AW~ YAKIHG ADONESS STAEET OR R i O. MO CI7Y pR /pNM STATE IIP
Nancy Pettey ,,,3224 C. West Lake Drive Fort Pierce Florida 33450
SURIAL. CAEWT1pN, qEYOVAL.OTNER(S,pKN~/ CEYE7ERYOR CREYATOqY-NAYE IOCAT10r1 C1TY OR TQNM STATQ ~
' s Buria2
- 18i i~hite Cit Cemeter Fort Pierce Florida
: vu~ruc owECr ,~/ANS cuwFrui ?.a~ ~DO~ESs
p ~ ~ ,,,Baird Funeral Home 901 N.7th.St. Ft.Pierce F1a.33450 ;
2h To IM Ow1 d~I O~~M occwnd u uy uno~, tlW ano W+ct an0 a,~ st ?t•. t~+r~ ON~inO P~ onG1 eue
a v»~~aw
n~ln~+~O oorroe M~ «ar~e W w ?
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WTE SICJED! . ri) MOUR OF ATH ~r DATE S~GNFO llfo. OiY~ Yr./ MO{JR Qi pEATM
p, j~ ~ 4:00 P. Y V~ zlp Itt Y
r NAYE Of A Tf P'NYSICIAH IF OTMER 1HAN CERTIf1ER /Trp~ o~ ireN/ PwONOUNCEU OE~D!?b. O~r- y~/ P'RONOl/qCEDOEADfNOUr)
p ~ ~?i0 OM Zt! AT y
wu.~ ~uvo ~ooaESS os ce++r~,~n c??+rycw.. ?~acni exw?aweni r~rv a aM~~
n Kenneth S. Friedman, M.D.,1700 S.E. Hillmoor Dr. Suite 202 Port St.Lucie Fla.
- NEG~STRAq DAtE REC£~VED 6v R£GISTqAA ~Yp., Oq, ~r.)
- - z7 March 7, 1985
z~+ isr..n,.., ?
2~ ~YYEpATE CAUSE ~fN/EA ONI/' ONF CA VSE oER tlME fON fU. lOi. AMO Ic} ~ ~ tnMrvY ON~Mn wy~t ~n0 O~~M
- - - 1~1 ~ I
~ ~Jf~ ~~r G' vs .i ~t~s. ~ Q 1 i ~ ~'"l I` 1
bllE TO. On AS w CONSEOUENGE (~~Ys) w~eA p~v~ rM eiuss (q - L~st u~drM4 «~4 ~nwrsi e~h.w+ onwe r+e awn
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{E~ /7 P ? O C ~P / C` ~ i ~ ~ / C' A i / ~ / ~ f C~ U _r' ~ ( r 1
Ol1E TO.OR AS A CONSfOUENCE Of. I Im~rvY OM~rw+a+~M 1+0 eNln
„ ~
?AR~ OMEN SIG/~1~/INi CO'~~K)'~R-CarfO~di{ COTAAnO b Or~ Ot ~O ~~O b c~us! ~ GART I W ~ART ~ ~i fFY~lf. N'AS Tl#RE A 4UiOKY CJ\1E 11EiE~ME~ TO 4E~1G?l
¦ PfiEC~t4NC~ 1Y iAST ~ MON7+b'' ~yw EXA~IrE lw R MI
2jt_ raC~ no n ~ x
~MOMICi ~ aC~UMOETER~p?$DlSptAr) DATE Of lWl~i'Y (1.b. O~Y. r~.) 1:OUQ OF INJVR~ DESCRISf MOW iNJVRY OCCVNAEO -
i7y~ . ?.a 7fD 2h Y 2~C
~C~1f1 S1Z, ~~UqV AT WORK fS~e/p VLACE Of R{JURY-M ~on». fam. slrNt. iKtory. otfK• LOCATION 5T1~Ei OH R F.O MO. C7TY OR 7011M STATE
8~s (Ob~deta~ YNO/NOI ewa~rq,e+c rsc+c,ryi
::l`'~.1' p(~OCM j7~ 711 27
~c t9.91.11/
696002
; n.,~b~? c~mty n,r. ro b. . m,. .nd ao.r.cr cop~r oF ttw l~c,r ~85 KAR 12 A 4:04
Rp~prs~s rooord on file in tht St. l~cle County llMhh 0~7~[f ~ 1=
m~n~ at Fors Pierce, Florida. - ~ FIL`_C
" ~ ROGE~. P' - ~
(yy~tning: Not valid unless raised seal of the 51~~;~~~~~ ST. LUi,~E : .
County Heaith Depanr~ent Fs affix~d.} , ~d + ~ ;
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