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2015.01.28 15:58 i PAGE. 1/ 1 1as-
NORTI I CAROLINA CCPARTMENT OF HF,ALIH ANU HUMAN St HVICES
N.C.VITAL RECORDS
CERTIFICATE OF DEATH
REGISTRATION
DISTRICT NO. LOCAL NO. COUNTY Of DCATI I STATF Fll F NO__._..t.
-._-.... .. • .. ...-
DECEDENTS LEGpL NAM --
E .
e.FIRST lb.MIDDLE I.c.LAST 1n tit/FFIx le,LA9i NAME fiRl)ri TFJ Fi1;ST
TYPE/PRINT IN MAHHIA{j'r
PERMANENT ', 0 t a n 60
' , *c t
BLACK OR
BLUE INK '.aka aka aka
2.SEX(3a A(3t•LAS 30,UNDER 1 YEARi3u.UNDER 1 DAY 4,DATE OF BIRTH(MunllODay/Yan)S.9IRT1•IPLACE 6.DATE OF DCATI I(MonthIDayNA.i)
I_ ll 1 HIH r Hi (Yrs) (County/St:do or frnoiyn Country)
ro /'� Months Drys lluurs Minuses �"�" �G
i II II CXLi ra,ys. t1. 1 `?1 f�,,n�,,, . 9- Zv1(p
w,PLACE OF DEATH(Chock only ondT-
7a.IF DEATH OCCURRED IN A HOSPITAL I7b.IF DEADi OCCURRED SOMEWHERE OTHER THAN A HORNITAi •
10 I IT Inpalrrnt T HRIOrtpabant U DOA f G Hospice tecill11 0 NurainS,home&Lalfl term care faciiity C)Decedent's borne(]Other/Specify}�•��,,,�.
-' is :'III Y NAM('(It not InetItotlon give street end number) 7d.CLTY OR TOWN 7o.COUNTY OF DCATI I
5, U+in n i1 ti,,, L.4 r4� A�w C{h. r ! �:�,,c5�c ( cz kuk
3 A.MARITAL STATUS tt.SURVIVING` i:; rave name I a DECEDENTS USUAL OCCUPATION lob.KIND.., BUSINESS/INDUSTRY
❑Mnrnnd ❑Married,hot snpantnl fl *owed pnnr to lir.,t m,ariagn) (T)n not;Imo rrttnen)
U Ulvorceo U Never marneo U Unknown
n ill.SOCIAL SECURITY NUMBER 12e.RESTOENCE STATE-OR FOREIGN nett INYR9--i7b•eUIINIY 12c.CITY ORTOWN
r.
„,I2d,STREET AND NUMBER 12e.INSIDE CITY I rian riv,DOM- 1:S WAS DETtOHN I tvhrt IN
D Yoe ❑Nu U S ARMED FoF
9r l RC Ti>❑Vrs ❑Nn
14.4 1)0C0IS-N I'S 5UUCAI ION(Check the box that 15.DECEDENT OF HISPANIC ORIGIN?(Check the 18.DECEDENT'S RACE(Chock ono ur moor mum to in diunu what uic
W.i hrol dcax.rihn::the highest engrrr,or town Of adnnct box that heat deecrrbee whether the decedent Is decedent oonaidered himself or herself to be) •
r_ cunutkatd at the time of danlh) Skin/11Mi::naninft atlnn Chc.W 1110"Nd(x)x It ❑White 0 Other Asian(Specify)
p1 i ❑81h grade in lass docndont Is not SpanirhiHinpanlMA Minn) ID Rack 9r African American •
Urm 0 Nu,nut S mist+/I lisbanialLutinO
) 0 9Ut-12U1 g+add,no dipluinaP' a Atnenuen Indian Or Alaska 0 Native Hawaiian •
w ❑High school graduate or GED 0Onwlete0 U Yee,Mexican.Mexican American,Chicano Native(Name of the enrolled or U c;uamanlen or Chamor(0
o U Some college credit,but rib degree ❑Yon.Pnnnt Rican •
•
priutilr,l!rite+) o panto)
O U Associate degree(e.g.,AA.AS) ❑Yes.Cohan ff Amer Paoo*C!Vendor($t)bpfy)
w
(}HdChe!01'a 0e9te6(e.A..BA.AS.Et,} fl Yns.nthrf fipnn,shMrspanrGLadnd(lip0b f"f) ❑Asian Indian CI Japnrw^m, ......
:Jr O Master &gm:a(mg MA.MR.MI-ng.Mtd.MOW,MBA) ❑Chinese ❑Korean ❑Other(Specify)
Q Drclnr:ur.log.,PhD,EdD nr Proir••innal dognr.
O�.y.,MO,DOS,DVM,Li 9,JD)MEM r ❑Filipino CI VOtnamCSr,
17.FATHER'S NAME(First,Middle,Leal) 18.MOTHER'S NAME PRIOR TO FIRST MARRIAGE(Finn,Midd!n,l.nol)
Iga.INFORMANT'S NAME I!Ib RFI Al IANSHIP In 110(70I11.N'I 14I0 MAILING ADDRESS(Street and Number.City.State,DP Code)
CUM 20n MFTHOD OF OI7;FAGiri ION I'I Hors' If Dr)meb0n 20F.PL ACE OF DISPOSITION(Name rdnerneirry orrmalnry. l0Un I.QUA I ION((Jily or low)and 0ta10)
❑Dnnatinn Tl Fntbmbmbnt fl Nomura tram state other plm:c:)
D Olhrr(Specify)
21a.31GNATURE OF FUNERAL DIRECTOR 21b.LICENSE NUMBER 121e.NAME or EMBALMER 2111.:Wag-.NIikARER-
' 22 NAME ANfS%iT1fTRFSS OF FIINHHA(,HOME
,II,,,'_^I 23.Part 1.Enter the,chain of events(ill snasrc,'oij,mc.0r rxfrxlin(t�KatTnns that 0RCgly causer]the Peel,DO NOT enter terminal events such as cardiac arrest. Approximate Interval:
CL"Inn:'.^ 'rI Iterpirakoy:,rorl,u,vun!rirular Ilt rill:rlinu wilhnul uhrtwing Ihm rtinlogy urn lit,,;h,r.and/or h Enter nnty nor:raus0 nn a line 00 NO!ANRIOIIVIA I I, Onset t0 death
IMMEDIATE CAUSE J
'd (final discuss of purulilion , f f'�,[3 Lmft.
i.,E m resulting in Ile Ur) J{ Ude 10(or as a consequence Oq
'»`y v j Sequentially list Condition,
M L 'A deny.!ead!ng to me...lion u, .._. ......_.._.._____ .._.. ...._._. . _�. - ---_. .. ..
f to N H E k Ii sibn nn!inn 0 Fntrr toe D:rr.tn�nr a$a GOr5RgU0n0e Of)
w k F t k w UNDERLYING GAIUGE. a _
a _V.6 Hs (disea:x or injury thot '"' Due to(of as a consequence of)
Z t 3 c z <, initialed the ever,ks fenulling
o iG in death)LAST
/
� PAH t ll,S)Umer significant Condlt;wma CcnVlbvUtvy to daalR but not resulting in this under 24;:.WAS AK AUTOPSY PERFORMED? 24h.WERE.AUTOPSY FINDINGS AVAh AR F
w m t ' v ca :n u own in RAH r I. ., as ❑No TO COMPLETE TI IC CAUSE or prim I?
n terra.O Nu
0 , 5, r ru L)1.l.,1-+
d .i:, ..__.... ...._..... _...
to e q E 2S.MANNER OF DEATH 26a WAS CASE REFERRED l'D 27,TIME OF DEATH 26.DID TOBACCO USE 29.IF FEMALE.
m N U n 1:1 ❑Namur l O Hnrniaidc MFDICAI FXAMINFR2 (Appnxirnatc) CONTRIBUTE TO DEATH? ❑Pregnent at time of death
,,,,,`.,' CI Arnidnnlrelpurnliny �f!n; Nn 1 I Yr,.4 13 Probably 0Nnt minivan]within pie year
,,3-a u , El i ❑Suicide Cornice be 25b.IF YES Cl No �8llnknnwn 0 Not prey thnent,but pregnant within 42 days of dea
i
Q a e° I 9etermeted T1 Obcbn d by MedIcel } 4 0 Nat prngnnnt,hot nn:gnnnt 43 tfay s In 1 yr m.Worm Aneth
!D r? o Examine! L ❑Unknown It eraynonl within the lx1St year
30.DATE PRONOUNCED 31a.DATE OF INJURY 31 b.TIME or 31c.INJURY AT WORK731d.PLACE OF INJURY•at home.,farm,street. ]to.IF TRAN$POHIAI ION INJURY
(Month/Uey/Year) (MonthlDayreeer) INJURY 0 Yen O Nu factory,ufiior,buikfiuy,de. SPECIFY:
MEDICAL ' _ y ❑OrivnrIOpmah,r
EXAMINER 1_-� r. C u}b ___ ❑Passenger
ONLY 311.DESCRIDC IiOW INJURY OCCURRED 3t9 I OCAI ION OF INJURY(SlreetlNumberICltWState) CI Pedestrian
❑Other(Specify)
MINI 32.CERTIFIER(Claeek only unu)
Cei atyymy 04,n:intenti n,prrc'ilionerlphysiri:ln arsirwnm To So Mee of my knnwinnge tooth rxrlmcn at the time.date.and place,and due 10 The cauae(si anti manner stated.
Medical Examiner-On the basis of exahlinetiur,urullur investigation,in my n(nnihr*oath mooned of lh0 Imo,date,and(lace and due to(he cause(s)anti manner stated.
33 . GNATU 4NO TITI, OF C£RTIF 11)31i'..I( t RFNUMAFH 33c DALE SIGNED(MdnNVDayNOer)
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.1't AME ANFi�/A� +CSS OF_C )Ihltht' nr♦(!egl U.DATER I„T'CRCU2fY STA'fC
�n r C . ro � ti�a-' � � S`'�c 1 Z. (5C-,}U,t_ •: �`Qs
4a rC)H I()CAI.HIK Ib'I MAR(Name) '35.DATE fILCD(Month/Day/Yore)
)1
DATE C:oRRF(:TF.D oFeeray/Y'rf- ITEMS)CORRECTED:
"'!rid'U'Z IYFM AMI-Nt1F[]•
:R_,saD„,m,n., DATE AMENDED(Mu/Day/Yr) (•S)
Y c.ups.RETAonS _,,....... ____...__
AN-29-2016 09:41 From: ID:GREENE FUNERAL SERV Page:001 R=89%