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H,yrpppK OECEOENT-NAME iIHST t~1~DOlE LAS~ SE7( DATE CK OEATHi4o Db
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~ ~ ~C3RER RALTP ~ F~emale , ril 23 19R5
6603 RACE-~q K'fvle B+act AGE-Ln! B~~~Wy UNDER ~ YE~R uNDER ~ DAr O+?TE O~ B~RTHi~IO D~r ~ COUNTV pf pEATN
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- .~ite 69 so x 6 June 3 1915 St. Lucie
CIT'v, TOy1M Oq IOCATION Of OfATN HOSOiTA~ OR OTHER INSTITUT~QH-1WmeNinpl.nFlM~ g-.e f~~s~rs;p`y,rnpN~ if HGSP Op ~NST ~~n~ c••e
7b _ T~~~ PQrt S~. Lucie Ho ital OP ER+e~ Hm tnpa:e^.. c;~._
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STATEOf81RiH(l/nW.n C~TIZErlOF1NMATCrJUNTqY ~/AqRiED NEVERwuHFiEO. SVRViviNG5POU5EiNr~h.p.~~m~enn~rn~~
7 Q U S A. nam~ count+y ) W iDOWE O. OI V OAC EO {Sp~t d~ )
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SOCIAL SECURITY NilAlBER USWI OCCUPA~~ON fG.rs ~~na ol ~w~ Con~ Ou~~ng Klt~q OF 9USINE$$ Op INOUSTRY
~ 155-07-5319 A,lachine ^'~Opera,tor,•
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RESIpENCE-$TATE COUNTtl C1TY. TOWN OA IOCAT1pH STREET ANp NU48ER INSIOE C~Tr ~;y
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,wFlorida St. Lucie ,k Part St. Lucie 702 SW Nichols Z~erraoe Yes
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fATMER-liAwE ~IRST 4ipOtE LAST 4tOTr~fH-MwiOENMwMf FlRST M~D~IF IAST
Y ,s ~t Jo~ui ,6 ~va Mae Salm
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~ j WFOqWNT-HAYEl~YO~ w A~nr/ IYAiL~NG ADDRESS STqEET OA R f O NO CITY OH TpWN STATE Ii~
Leroy E. Raup „0 702 SW Nichols Terraoe Fort St. Lucie Florida 3345~
BUAIAI. CREMAT~ON. RFWOVAL OTHERfSpsG~~7 CEMETERV OR CREAIATORY-NAME LOCATIQ~~ CITY Op TOWµ $TATE
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- Forest Hills Mem. Park PaLn Cit Flarida
~ FU L TOR-{ ~t ~UNERAL HOME A~K ADDRESS
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j i , 1504 Floresta Drive Port St. Lucie Florida 33452
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~ ~ t d my M occurr~O st tne t~me. Oate an0 piau u~ t7ue ~ 21a O~ t~e Ots~s of t¦~m~nadon anG.~or w~vye.qaal+on. rn my op~n,pn Wa7n occ~~•e0
e ~ 4us~lsl tta . a~ tvne. ~ate aM D~+ce uW Out t0 the caus~lsl s!NeO
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OArE StGr~ED~MO. D~y. r. ~ HOtIAOF QEA7H ~Y DATE S~GNEO r~uo Dar~ v. I NOUR Of DEAiH
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' ~ NAIdE Of ATTENDING VMYSiCIAN IF O?HER THAN CERTIFiER i 7Ype o~ Pnnt~ E p DRONOUNCED DEAp !MO Dty Yr / PRONOUNCED DEAD~HO:.r~
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~ ~ NAME ANO AOOAfSS OF CERTtFIEH ~PMYStCUN At~DICAL EXA4MER1 (lypa orOnnt~
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~ _ - REG~STRAN ~ O~7EREC6vE08rREG+SiitwR~Ma.Dar rrr
i z~~yg^•~u.•, ~ - ~ 23b April 26, 1985
N IYMEOUTE CAUSE ~Fk1fli ONC v OHE CA P LfNE iOR ~i~. DI. AND 1N ) • I lnter~a! befreen o~ur a^: xa~-
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DUE TO. OR AS A CONSEOVENCE OF (Cand~DOrKS) rh~cfi pavO rqp 1p taust (a) - Zy ~ndeyyu~p ~~x y~? Inllrva: De~reen onset a-.c oea•'
l~) l~~d~a~s! C7~S ~1~fi'~ ~`~lC~~. 1~~1~t..
DUE TO. OR AS A CONSEQUEHCE Of ~ Interra~ be!wee~ o+~v: ~nc a~••
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~A1ti O'~ER :JGN~K'aNi COr:q~iCX+S-Cmw.un cac.w.rq x, xar a,: ra .sr.eo •o a.se p.~n ~ P~a? i~ai IUtT 111 rt FE~I~4E wA5 7nERE ~ ~uipcsr C~ISi REFECatEO'O v=_:l_i_
t ~REGk~f:C'/ W'ME PAS' 3 NONTHS~
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I~o0aDy1 ACCiDENT SUiG~OE or pATE OF IWURY (MO , p0y, Yr ) HpUq OF INJUFiV DESCAiBE HOW iNJUqr pCG_tpqEO
7~9 t+ONICIpE p tp~pETER?AINEOISp?t~ryl
27a 17D 2TC b! 270
HFS Fpm Sf2. INJURY AT WpRK (Sp~uly P~ACE OF INJUfiY-A1 nom~. l~rm sU~st fxtOry p}bc! tOCAT7pN STR£E7 OA R f D NO GTV OH TOWt+ ~ STA~E
~ Y~id NOI Du~~O~ng !tt ISp~cdyl
p'8'v'iCUL l~Ofl~ 77i 271
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i Mrob~? Cwti~fy 1hM fo b~ a trw and oorrect copy of th~ Loc~~ ~~"Z P3 ~12
ibph~trsr~ reoo.d on file in the St. Lucie Counry Heafth Drpart-
ti~1t et Fort Pierce, Florida. i FILE? ;~ty~.
(Wsminq: not valid unie>~ ~ 3~se:i ;ea~ of the St. Luew - ROGER F~~f
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County Heafth De .~•r-ent is affixed.) ~ ST LUCI~ -
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