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Tremblay, Richard Doc.NO. OFFICE OF CERTIFICATE Ur utA I n 35-05-20-99/08/20 VITAL } / >--> STATISTICS . $tatr .�f EI�X. are (107) [ STATE FILE NUMBER LOCAL REG NO. DEPARTMENT OF HEALTH AND SOCIAL SERVICES 1.DECEDENT'S NAME(FIRST,MIDDLE,LAST) 2.SEX 3.DATE OF DEATH(MO.,DAY,YR) DECEDENT Richard F. Tremblay Male October 31# 2006 .•C. . 4.SOCIAL SECURITY NO. 5A.AGE(YRS) 5B. UNDER 1 YEAR 5C. UNDER 1 DAY 6.DATE OF BIRTH 7.BIRTHPLACE • etat,p Cet MONTHS DAYS HOURS MINUTES (MO.,DAY,YR.) (CITY AND STATE OR FOREIGN COUNTRY) J3 It co c 01/16/1921 Caws Palls, NY t ›,w.. 8.WAS DECEDENT EVER IN 9.ANATOMICAL GIFT 10A.PLACE OF DEATH(CHECK ONLY ONE,SEE INSTRUCTIONS ON OTHER SIDE) ▪w o. U.S.ARMED FORCES? HOSPITAL OTHER m- p CONSENT NOT NURSING OTHER 5 E N.t.-0 si YES ❑ NO ❑GRANTED GRANTED ®INPATIENT 0 ER/OUTPATIENT ❑DOA ❑HOME ❑RESIDENCE ❑(SPECIFY) w u.Si o 10B.FACILITY NAME(IF NOT INSTITUTION GIVE STREET AND NUMBER) 10C.CITY,TOWN,OR LOCATION OF DEATH 10D.COUNTY OF DEATH iivc ,.c medicalCenterDover Kent Q A V m a 11.MARITAL STATUS-MARRIED,NEVER 12.SURVIVING SPOUSE (IF WIFE GIVE MAIDEN NAME) 13A.DECEDENT'S USUAL OCCUPATION(KIND OF WORK 13B.KIND OF BUSINESS/INDUSTRY .re, w 6 a MARRIED,WIDOWED,DIVORCED(SPEC.) DURING MOST OF WORKING LIFE.DO NOT USE RETIRED) a o 9 Corr► Supervisor Construction 88 °Ent Married W �2 C= 74q.RESIDENCE-STATE 14B.COUNTY 14C.CITY,TOWN,OR LOCATION 14D.STREET AND NUMBER CC C ; € Kent Laneacu3C Delaware Dover 37 Cody .J 2 ' ' RACE- R A'a to c 14E.INSIDEOR V LIMITS? 14F.ZIP CODE 15.(SPECIFY NO ORAS DECEDENT OYES,I SPECIFYOCUBAN,MEXICAN, 16 BLACK,WHITE,ETC.I(SPECIFY) 17 HIGHEST GRADE COMPLETED) W `- cl (YES OR NO) UERTO RICAN,ETC. 0 NO 0 YES ELEMENTARY/ COLLEGE z y c �` SECONDARYO +�^ (1-4 OR 5+) 7v c2- a Id a 2't_m (Specify) .. / I'aa 3m ` 18.FATHER'S NAME(FIRST,MIDDLE,LAST) 19.MOTHER'S NAME(FIRST,MIDDLE,MAIDEN SURNAME) PARENTS Francis Tremblay Grace Silly 20A.INFORMANTS NAME(TYPE/PRINT) 208.MAILING ADDRESS(STREET AND NUMBER DR RURAL ROUTE NUMBER,CITY OR TOWN,STATE,ZIP CODE) 1 INFORMANT baler& Tnamblay 37 Cody Lane, Derr DE 19901 21A.METHOD OF DISPOSITION 21B.PLACE OF DISPOSITION 21C.LOCATION(CITY,TOWN,STATE) 1 REMOVAL (NAME OF CEMETERY,CREMATORY,OR OTHER PLACE) 2.BURIAL ❑CREMATION 0 FROM STATEery t kri ❑DONATION ❑(SPECIFY) Pik Vie./ DISPOSITION 22A.SI N RE OF FUNERAL DIRECTORT-Ii 22B.LICENSE NUMBER(OF LICENSEE) NAME AND A R OF CI ITY fars-,y Funeral Halle ► 4,, 10000444 mil 635 ChurebeariS W. j>t war DE 19702 24.REGISTRAR'S SIGNATURE"`'� 25.DATE FILED(MO.,DAY,YR.) COMPLETE ITEMS 26 A-C ONLY WHEN 26A.TO THE BEST OF F-KNOyLEDGE DEATH OCCUR 3.52 Y T 1 1E,DATE,AND PLACE STATED 265.LICENSE NUMBER r26C DATE IGNED -� ,, URE AND TITLE JII (MO.,D Y,YR.), PRONOUNCING ABLE AT TIME OF DEATH CERTIFYOT IL- -.- i x yJ �n�_,•<�.� / r''"" �. J`/ - OFFICIAL ABLE AT TIME OF DEATH TO ►.s"'"""?Z - - ,,J ''5.,..�" , e - '-, /#r, ;-' - CAUSE OF DEATH. -� �" alITEMS 27-29 MUST 27.TIME OF DEATH 28. TE. NCED y�_A_tC D '�"` 29.WAS CASE REFERRED TO MEDICAL EXAMINER?(Y OR NO) BE COMPLETED BY ❑AM '' tw',_ii_;,.- Y PILE NURSE PHYSICIAN OR HOS-+ ```IFF�y�-' `i �^y J/ )t �1 WHO PRONOUNCES 30A.CERTIFIER DEATH (CHECK ONLY ONE) ❑CERTIFYING PHYSICIAN(Physician certifying cause of death when another physician has pronounced death and completed item 26) To the best of my knowledge,death occurred due to the cause(s)and manner as stated. SEE DEFINITION ON OTHER SIDE t,F-IP.#ONOUNCING AND CERTIFYING PHYSICIAN(Physician both pronouncing death and certifying the cause of death) ® 1'o the best of my knowledge,death occurred at the time,date,and place,and due to the causes)and manner as stated. MEDICAL exAMINER and due to cause*, - [(©F tteliis-Qfexamination 0n to R�opkti€m,death omitted at the time,z�ate,and Ittacei and manner asstated 30B.SIGNATURE AND TI }d'CE FIc,gg ,, •#�`jr - -_ 30C.LICENSE NUMBER 30D.DATE SIG D(MO.,TAY,YR.) { p '' 31.NA ND iRLSS UY'- I HO LETEB 5E OF DEATH(IT )(TYPE/IBINT) ct 32A.WASAN 33. NNAT (MO-DAY, 11. 37-[kESG(i1fk_73C1 -tk1dU.F3 xRR D t Q AUTOPSY F F DEATH (1K0,bAY YR IN,lUtiY J II PERFORMED? ? - , .. , , , ,, -, ,,,, ,,,,,,,i,,,,,,,,::,,, ui m= `� "�'� 'ATURAL - - QF Q ❑ YES+y, SIO ❑ACCIDENT - Q IJJ 32B.WERE AUTOP- 35.TIME OF MUURY - 0 YES 38.PLACE OF INJURY(ATRLkHE FARM,STREET,FACTORY OFFICE BUILDING ETC.(SPECIFY)) 0 0 SY FINDINGS ❑SUICIDE - AVAILABLE PRIOR J LL TO COMPLETION OF ❑HOMICIDE NO - - ` W CC W CAUSE OF DEATH? D 39.LOCATION STREET AND NUMBER ON RURAL ROUTE NUMBER CITY OR TOWN,STATE)Gti: ❑NVESTGATION L1AM U< 4❑ YES ❑ NO .-- - °PM - - - N ❑UNDETERMINED -- ' v Q O AUTHORITY FOR BURIAL,TRANSPORTATION AND REMOVAL W>- = This Burial Transit Permit, when completely filled in and bearing the signatures of the pronouncing and/or attending physician and Wcu that of the Funeral Director in item 22A,becomes authority for Burial, Transportation and Removal of the above named Decedent. a= This permit is not authority for cremation.Separate authorization must be obtained. Z CC I-= CEMETERY OR CREMATORY AUTHORITY SHALL FILL OUT SECTION BELOW O Q 1- The Decedent named above was buried❑cremated❑in the cemetery or crematory in item 21B. J 2?� ❑ BURIAL WAS IN Section U N CAS Lot 17 3 3 Grave 1 . The appropriate entry in the Cemetery Crematory F.W 11J registry h een m e. l 0 5 1- ' itJ `i tt/e oC ICI QW V Signature Sexton or other person in charge Date signed o This Burial-Transit Permit must be signed above by Cemetery or Crematory Authority. If no full time person is charge of the cemetery, Illkllih.... the Funeral Director may sign as Sexton. This Burial Transit Permit is to be retained by the Manager,Superintendent, Caretaker,Sex- N ton or other person in charge of Burial,Entombment or Cremation or if none,then the Funeral Director. (3)BURIAL/TRANSIT PERMIT