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1. 51am 1 71L Numecn NAME OF DECEDENT - FIRST (Given) n �••, 2. MIDDLE PAUL 3. LAST (Family) HOWELL CI ERNEST p AKA. Z Oo ALSO KNOWN AS - Include full AKA (FIRST, MIDDLE. LAST) 4. DATE OF BIRTH mm /rid /ccyy 1 5. AGE Yrs. L IFVNOER OHEY 88 Manlhp ; De p IFUNDEAl, HOJRS Na ra ; M N 6. SEX M N 9. i BIRTH STATE/FOREIGN COUNTRY AL 10.500161 SECURITY NUMBER 422 -16 -0020 11. EVER IN U.S. ARMED FORCES? X YES O NO 0NK 12, MARITAL STATUS/SRDP' 51729010.00) WIDOWED 7. DATE OF DEATH mm /d0 /ccyy 09/26/2011 8. HOUR (20504,0) 2340 17. 3,1.N303030 3. EDUCATION- Hghesl Leve1Oegree (see worksheet on bade HS GRADUATE 14115. WAS DECEDENT /6SPANIOILATINO(79SPANISH? (n yes, see w1MSheet on bade ❑ YES X NO ' 18. DECEDENT'S RACE- Up to 3 races may be Wed (see 0 sheet onbacH CAUCASIAN USUAL OCCUPATION -Type 01 work for most of life. D0 NOT USE RETIRED RETAIL SALES 19 KIND OF BUSINESS OR INDUSTRY (e.g.. grocery store. marl construction, employment agency, etc.) VACUUM AND SEWING MACHINES 19. YEARS N OCCUPATION 43 _ USUAL RESIDENCE 29. DECEDENT'S RESIDENCE Mara and number. or location) 10766 JOEGER ROAD 21. CITY 22. COUNTY/PROVINCE AUBURN I PLACER 23. ZIP CODE 95602 24. YEARS IN COUNTY 26 25. STATE/FOREIGN COUNTRY CA 1NVW -tlOiNl 26. INFORMANT'S NAME, RELMION5HIP PAMELA NAHIGIAN, DAUGHTER 4526 MCROBERTS (Street M number. city and zip) SPOUSE/SRDP AND I PARENT INFORMATION 28. NAME OF SURVIVING SPOUSE/SRC/Pr -FIRST 29. MIDDLE 30. LAST (BIRTH NAME) 31. NAME OF FAT14ERIPARENT -FIR5T ERNEST 32. MIDDLE LESLIE 33. LAST HOWELL 34. BIRTH STATE AL 35. NAME OF MOTHER/PARENT -FIRST HATTIE 36. MIDDLE MAE 37. LAST (BIRTH NAME) WILLIAMS 36. BIRTH STATE AL _ FUNERAL DIRECTOR/ LOCAL REGISTRAR I 79 DISPOSITION DATE mm/ddccyy 10/03/2011 40. PLACE Of FINAL DISPOSITION RES PAMELA NAHIGIAN 4525 MCROBERTS DRIVE, MATHER, CA 95655 41. TYPE OF DISPOSITION(S) CR/RES 42. SIGNATURE OF EMBALMER ► NOT EMBALMED 43, LICENSE NUMBER - 44. NAME OF FUNERAL ESTABLISHMENT NAUTILUS SOCIETY 45. LICENSE NUMBER FD 1459 46. SIGNATURE OF LOCAL REGISTRAR ► RICHARD J. BURTON, MD g; 47. DATE mm /rid /acyy 09/28/2011 PLACE OF CAUSE OF DEATH DEATH 101. PLACE OF OEATN OWN RESIDENCE 102. IF HOSPITAL, SPECIFY ONE Ell IP O ER/OP. DOA 103. IF OTHER THAN HOSPITAL, SPECIFY ONE ❑ IlO;A lce ■ Ron,oO.TC x D O Other 104, COUNTY PLACER ( 105. FACILITY ADDRESS OR LOCATION MMEP.F. FOUND (Street and nUmher, or location) 10766 JOEGER ROAD 106. CITY AUBURN 107. CAUSE OF DEATH Enter the chain 01 events - -- 5000050. injuries, or complications -- that dreAN caused deaN. DD NOT enter teminel events such or ventricular fi6Mabon MONO showing the aliolagy. 00 NOT ABBREVIATE. Tune Interval Between Om? and Death 106. DEATNPEPORTE0T000RONERI X YES NO err 2609 es carded arrest reparatory arrest. IMMEDIATE CAUSE IN RECURRENT NON -SMALL CELL LUNG CANCER (An (Final diseases ; condition resulting in death) IBI (1311 Sequentially, list 109. BIOPSY PERFORMED? X YES • NO X conditions. if any, on Line A. Eller Acause j0) (CT) Use UNDERLYING CAUSE (disease or 110. AUTOPSY PERFORMED? III YES X NO Nll,adt (DT) initiated me events 03) Ring in death) LAST 111. USEDINDETERMIMNG CAUSE? O YES NO 112. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING IN 1141 UNDERLYING CAUSE GA/EN IN 107 NONE 113. WAS OPERATION PERFORMED FOR ANY CONDITION IN REM 107 OR 112? al yes. list I I operation and date. LEFT THORACOTOMY AND LEFT UPPER LOBE 03/17/2006 113A IF FEMALE, PREGNANT 1N LAST YEAR? C1 YES III NO . 0NK PHYSICIAN'S ;ERTIFICATION 114 I CERTIFY THAT 10 THE 8E51 Of MY KNOWLEDGE DEATH OCCURRED AT THE HOOP. BATE, AND PLACE STATED FROM THECAUSES STATED. Decedent Attended Since Decedent Last Seen Alive 115. SIGNATURE AND TITLE OF CERTIFIER z�L. r (4 /p ► JULIE L HERSCH M.D. @` 116. LICENSE NUMBER G57788 117. DATE mm/dd/ccyy 09/27/2011 IA) mmlddicoyy (B( mmlddlccyy 02/09/2006 08/23/2011 118. TYPE ATTENDING PHYSICIAN'S NAME , MAILING ADDRESS, 21P CODE FRANK TZE HSIEH M.D. 1600 EUREKA ROAD, ROSEVILLE, CA 95661 CORONER'S USE ONLY II 119. I CERTIFY THAT IN MY OPINION DEATH OCCURRED AT THE HOUR, DATE, AND PLACE STATED FROM THE CAUSES STATED. Inv Oak not be MANNER OF DEATH O Natural O sing Accident II Homicide O Suicide ❑ Investigation determined 120. INJURED ATWORK7 YES NO lNK O O O 121. INJURY DATE mr 44)00yy 122. HOUR (11 Hours) 123. PLACE OF INJURY (e.g.. home. constm0110n site, wooded area, MC.) 124. DESCRIBE HOW INJURY OCCURRED (Events which resulted in injury) 125. LOCATION OF INJURY (Street and number. or location. and city, and zip) 126. SIGNATURE OF CORONER / DEPUTY CORONER 127. DATE mMdd/ccyy 128. TYPE NAME, TITLE OF CORONER / DEPUTY CORONER STA TE REGISTRAR A 6 C G E 11111111111111111111IN1111111NNI1111II1111111111111I111N11111111111111II111 * 01000 001882234" I 'AM" CENSUS TRACT STATE OF CLUILIFOIINIAL. ERTIFICATION- OF VITAL RECORD 4 r II 0 wri I I lllIIl COUNTY OF PLACER 20121050 111 Auburn, California 95603 CERTIFICATE OF DEATH USE BLACK INK ONLY / NO EN SII�BE55, WHITEOUTS OR ALTERATIONS CERTIFIED COPY OF VITAL RECORDS STATE OF CALIFORNIA, COUNTY OF PLACER *000350511* This is a true and exact reproduction of the document officially registered and placed on file in the office of the Placer County Health and Human Services Department. 3201131002433 LOCAL REGISTRATION NUMBER 'ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE Richa d J. Burton, M.D. DATE ISSUED HEALTH OFFICER AND LOCAL REGISTRAR This copy is not valid unless prepared on an engraved border displaying the date, seal and signature of Registrar. PBNCO(RUV) Oft/09