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HomeMy WebLinkAbout0994 '7~~f;v~."~ ~ ~ ~ ~ ~ i r z CEIITiFiCATE 4F DEAT'M ~ i~~~~ F~ORIDA see ~wppK OfCfOE?+T-?u~uE i~RST YWD~E LAST SEx DATE OF DfATNl4n. p~Y. v~J POR MgTMK'~?X~ 1 2 ~ 6L02 NACE-~ p. YYwr 9wct AGf -last B~nnO~y UNOER t vEwi1 IMDER ~ OAY OATE Oi BINTHr4b. Diy, Vi ~ ~p~~TY OF DEATN ~Q ° ~m ~ncw+. Kc rSOK~rr~ ~ r•~ ~ iu05 ~ DAYS ~+Ot~iiS ~?t~NS 4 Sa SO SC 6 7i ~I~Y. TONM OR LOCATION Oi QEATH HOSW TAl OR 07HER IN$TITUTfON- Wm~ (I/ nOt 1n MInM. qny ~trMt ~nQ~unpp/ Ii Hp$p OR iNST. ll~t~tat~ OpA. Fort Pierct ~ .e Lawnvood Re ional Nedical Center aDEIIIRatient ,d STATEOFB~RTH~drrot~n C~f~2ENOFWHATCqUNTRV WHaiEO.NEVERMwpRrEO. SUAwYUVGSPOUSE1~f~rl~.p.r~rnadennan»~ U S A. M~f CO+iMrY/ W~OOwEO. OrvORCfO ~,Sp~c~1y1 s New York , U.S.A. ,o M~rried Rebecca Gib~on SOC~AL SECURtTV NUIlBEN U$UAl OCCUPATION rG~v~ ~~n0 of rorM AorN d~r~np KI/OOF e(IIShcVE$$ Qq lI~USiRY er~pfl0l r~Or~~~g hN. ~t~n ~l ht.iMl ~2 103-18-$S00 Mech~nic Boat liotors RESIOENCE-STATE COUNIY ClTY. TOWN Qp LOCATtON STIIEET AND NU4ISER Ih$lOE CITV lIM7T5 ~4 Florida ,.St. Lucie ,k Fort Fierce ~p10 Colonial Road A-6 ,,.°~'e~a"°t " FATHER-HAME FiRST M~DpLE LA57 ' MOTHER-MA10EN NAME fIRST MlDDLE LAST ~ ~S ~6 {ihitne > WfOqMANT-NwME!T~p~ a R~n~, M~~UNG A~HESS STREET OR R F D NO C~TY pR TOWN STATE ItP »o ' e Florida 33450 - BUA)AL.GREMATIQN.REMOVAlO11iEAlSplC4~1 ~CEME'EpvORCREMw7pRY-NA?IE IOCAT1pN C~TVORTOYVN STATE ~ t{i - erce Florida ~v~R~ roa~ i fUNERni NOME "o°REU 3015 Okeechobee Road ? 2Ca c cne Des~ o~ m knc••ea;e oea±n oct~•~co a.e ~ p+a=e ana o„e 21a On tne navs of e¦am~nai~on ana-or m~[ t on. m • i t t y~ ~ mY OWn+a+ Oeat~ occunW at tl~e r !O tne CduSl:S: fta1~C W lune. C~t! ~~A pIK! L'M Qu! fo iN! [au3lf3) stitlC ~ . ~ . ~ ~sw~n~r. «a Ta.) ? ' i a arr rr.) ? . D~TE 5!vNEO• ~1/o Day: ~ i MOUp OF p~A'~+ ~x OATE SiGNEO iMo. Day. vr ) HOUF1 OF OEATH W V~ ?90 " 7Y • M UU 2tD 2tt M NAMf OF ATTEND~NG ~HVS:C.AN If OTNER iHAN CE~TIFtER~7 ~ pr p~m!~ E" r ~ p PqONOUh„ED OE~p Uuo Dav ~ ~OnOiFJCED ~E~D1r~a~~; o~ o~ ~w r"i V ZOC 21A ON 71e AT t~l NAME ANC ADDR£5$ O~ CEa~iFiER 1PNr5~C1A4 MEQ~C~~ E1AMiNEA; ~Type cr C~~^•~~ 1 P. Viado M.D. 805 Vir inia Avenue Fort Pierce Florida AEG+STaoq 4 DATE RECEwED BY REG~57RARrMO, Dy. rr ~ z~~ ,s5.~.,~,~; CLc-~~C JI ~v 8~0 2~ MaY 28, 1986 1MMED:aTECAUSE 'F•.TfRONLyCNEGUSEPcaL~~Yf~Qp~ai.lD! AYD~u I~rttlrv~lp~MlMOnSlf~rMO[it~ ~ i rutr a ~ ~ ~ .r'.~ " ~~./1~-~~/~.~'- .,v f"Z,~'~~ j ~"r ~-L / 6uE 'O OA AS ~t COtiSEQ'vE!vCE CF (Condcdys; wrt~ y~ya,ra rrse to cause (a) - LKi ~n ng cause ~~n:er,ra~ xhreen w,se~ uW aeun G-_d~.~c,~`~,..E-S-J--,iv'~-- ,1:f~~ ~y.j'-'~-" -~.~./G-l/.2-'lr- ~ z ~3-,o~,GL ~D~ ~ OUE TO CR AS ~ CONSEO'.;ENCE O~ ~ tnten~t Dehreen onst! snd Oetl~ z4 _ ~j~ ~7.2/~~SG~-"7~'c:'r7C /cSC~=~E~~~- ~i'~~~~~ 3 ~MT .~•.acG c~.~- r..V.$- ~.'.'YS t t~.' Ora^ `•y •>Yed',~ Ca.Y 4.e. FAP' 3: ?AAT r 1G FEM3iE w15 r.rEaE ~ ~IiTQPSV CASc R~FE T~ ME ¦ ~.~cG'<I.'v:~ 44 Tr~E G,151 3 M~IT.~$~ t.es or roi EYJ.W+fp t5aa+~f M~ a ro) ~ 271_ ~~G"G~~/ +os:. ho~ n ~ ~vrooa~~~~ ~CC~CEnIT SuiCiOE w DATE OF INJURY ~MO Qly. Yr j reOUq OF W~URr DESCRIBE MOW iNJURV OCCURREO HOM1C~(}E o~u~+CE7EA~.t~tvfOrSWc~~i~ ~ ~'s~$ ~orm 512. 2,-a 7'D 7%c M 27a " INJUNY AT WpRK ~SP+o~r ~I~CE OF ~NlURY--At ~ome ~um stree( IactO+y ofhte LOCATION STREET Oit R F D NO GITY OR TUNrN STAT~ ~~~~M~ v~s w Nol ov~b~~g erc ~Sp~c~ry; •$'~'ALtS id1L10h3 17~ p;! Z7 33 OS 12~~'~ r JV~J,~ . ~Cl~'D'~/ --r-rSij"•( ~!115 'O C~f' d' lfli° dila COf(QCi COpy Ot LO~d~ . ! • -~e Cou~ry H~alth O~Part ~o~is'r,= . .,..~rc , ' , ar' o ' - _ • . ` . _ , seal ,r • '~~t L~~_~e f~~, , ~,,r~.; ~ . . . ,1U'~ 19 p 3 ~ 1 - ~ Cour• ; . ,.<~r ..:c-:; : • 2 - (V •'p. MiCLER, ~i. D, Fi:_~ . R~,; : i` ty Neasth _OfT~cer lcr- I Reg;strni Sj. LIICit . . , _ ~ _ r+i1~{ , . ~ S~ ~Mr (.OC~ R~i~+r~ - `--~oc~.504 ~;:r,~ ~94 t.. _ . - _ - . -