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t NAMME- FIMST'iiIp - <br />�' E LAST"',, . = <br />THE -R /90 <br />p EV. �$ERT� BEEKMAN BROWN D.D. <br />B R 1 <br />2'' SEX <br />MALE <br />�� , DEATH DAT (MO Day Vr 1 <br />� <br />4 <br />; <br />� <br />16 <br />STATE FILE NUMBER <br />E AGELAST BIRTH. <br />DAY 'Y!al <br />7 i <br />' 9 UNDER T YEAR ' 1 , 6 UNDER 1 DAY <br />I <br />7. BIRTNOATE OM, Day, Yr.) <br />10/5/13 <br />8 81RTH STATE of not in ' <br />USA give Country) <br />NEBRASKA <br />,9 CITIZEN OF WHAT'COUN767 <br />,U. S. A. <br />10 COUNTY O D6*7N -, <br />KING <br />MOS DAY 1 HOURS INNS <br />L�ATION O DEATH <br />E <br />i 'SEATTLE- <br />_ <br />2 It 69 OF R, N PO O T H A $• 5❑ � �STIS j tK)ME 6 007069 PLACE <br />74, <br />3 15 SMOKING <br />VEARS? I (709 01 <br />D la MARITAL STATUS - Marred <br />Nave, Mried w <br />E ar Wid00d. <br />N f ithE`� <br />A <br />15 SURVIVING SPOUSE Ut w le gee maiden name) <br />MAUDE ADELAIDE HOUGHTON <br />16 WAS DECEDENT <br />EVER IN U.S. ARMED <br />F n.cmw) <br />0 O <br />17 SOCIAL SECURITY NO. <br />530-34 -0053 <br />18 NIGH SCHOOL <br />GRADUATE' <br />n es NoI <br />YE <br />T 1 9 USUAL OCCUPATION (Gee sing of work <br />done Our 09 0094 of w044 ng 1.le DO NC <br />tfi MINISTER <br />20. KIND OF BUSINESS OR INDUSTRY <br />CHRISTIAN CHURCH <br />21 Was Decedenl of Hispan'C D0gin Or descent? (Ancestry) <br />(Spec ty Yes or No. If Yes specify Cuban Mexican_ Puerto Rican. <br />et 2 ND <br />72. RACE IWn) e. Blau. &saner Pac tic <br />Warta, Am Ind. Hr5pa1.0. Pc <br />5oe "I WHITE <br />73. RESIDENCE • NUMBER AND STREET <br />• <br />6924-40TH AVENUE S.W. ' <br />24 CITY /TOWN, OR LOCATION <br />SEATTLE <br />25. INSIDE CITY <br />LIMITS? <br />Yr <br />26. COUNTY <br />KING <br />27. STATE <br />WASHINGTON <br />28. ZIP CODE <br />98136 <br />P 21 FATHER'S NAME -.- FIRST. MIDDLE LAST <br />Ft JAMES BEDFORD BROWN <br />30. MOTHER'S NAME -FIRST, 14100LE MAIDEN SURNAME <br />JANE BEEKMAN <br />E 3 1 . INFORMANT -NAME <br />T ROBERT B. BROWN) JR. <br />32, MAILING ADDRESS STREET OR RFD NO. CITY OR TOWN STATE ZIP <br />2023 NORTHEAST JOSEPHINE DR., HILLSBORO) OREGON 97124 <br />0 33. BURIAL. CREMAT.• <br />S BU �K NI <br />- <br />34. DATE (MO. Day. Yr.) <br />5/3/90 <br />35. CEMETERY /CREMATORY -NAME <br />FOREST LAWN CEMETERY <br />36. LOCATION- CITY/TOWN. STATE <br />SEATTLE, WASHINGTO <br />5 _! V.; .: TO <br />//y� <br />N . �. I\ cn,t • r <br />o o <br />38 I[4,CILI di FuwtoJ Nallome <br />of west Seattle <br />y/ <br />283 S �.ACI�I . / 1 Sf iceei <br />Sea' ttle,' (Uaaltuujton 98116 <br />TO BE OM D ONLY BY TIFYING PHYSICIAN <br />TO BE COMPLETED ONLY BY MEDICAL EXAMINER OR CORONER <br />.p. TO THE BEST OF MY KNOWLEDGE. DEATH OCCURRED AT T 714E, DATE. AND PLACE AND DUE TO THE <br />CAUSE(S) STATED <br />C SIGNATURE yD TIT ► <br />E <br />R M. D. <br />.1. ON THE BASIS OF EXAMINATION AND /OR INVESTIGATION. IN MY OPINION DEATH OCCURRED AT <br />THE TIME. DATE, AND PLACE AND DUE TO THE CAUSE(S) STATE0 <br />SIGNATURE AND TITLE <br />x <br />T 42. DATE SIGNED (Mo.. Day 5r.l <br />F 4/30/90 <br />.43 HOUR OF DEATH (24 Hn l <br />1500 <br />44 DATE SIGNED (Mo.. Day. 1 <br />45. ■0UR OF DEATH (24 Hrs.) <br />I <br />E 46. NAME AND TITLE OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print) <br />R <br />47 PRONOUNCED DEAD (Mo. Dry. Yr) <br />48 HOIR PRONOUNCED DEAL <br />(2. HnI <br />f11 <br />i, <br />QFFI�E f <br />•SE ONLY <br />1 DISTRIC <br />Jr' I .,- <br />3 HOSPITAL <br />4 OCCURRENCE <br />5 RESIDENCE <br />6 TRACT <br />iu <br />i OCCUPATION <br />6 I <br />(0 <br />12 <br />13 <br />la <br />'.5 <br />16 <br />16 <br />19 <br />29 <br />21 Ili <br />22 QUERIES <br />23 <br />STATt O WASHINOTOW DEPARTMENT OF WEA t1-1 <br />VITAL RECORDS <br />L FILE NUMBER'. CERTIFICATE OF DEATH <br />LOC/s <br />N. NAME AND ADDRESS OF CERTIFIER - PHYSICIAN MEDICAL EXA <br />SETH B. FRANKLIN, M. D., 910 BOYLSTON AVENUE, SEATTLE, WASHINJGTON 98104 324 <br />5o. PART I. ENTER THE DISEASES. INJURIES, OR COMPLICATIONS WHICH CAUSED THE DEATH DO NOT ENTER THE MODE OF DYING, SUCH AS CARDIAC OR RESPIRATORY ARREST. SHOCK. OR HEART FALURE. <br />LIST ONLY ONE CAUSE ON EACH LINE. <br />IMMEDIATE CAUSE (Final disease or <br />condition resulting in death). <br />Sequentially list conditions, if any, <br />leading to immediate cause. Enter <br />UNDERLYING CAUSE (Disease or in- <br />jury which initiated events resulting in <br />death) LAST <br />51. OTHER SIGNIFICANT CONDITIONS- CONDIT4NS CONTRIBUTING TO DEATH BUT NOT RESULTING IN THE UNDERLYING CAUSE GIVEN ABOVE <br />N. ACC. SUICIDE. 90.. UNOET. OR 55. INJURY DATE (MO.. Day. 1 <br />PENDING INVEST. (Specify) <br />58. INJURY AT <br />61. REGISTRAR <br />SIGNATURE <br />x <br />ORK? (Yes/Nol <br />( <br />ICI <br />NER OR CORONER (Type or Prim) <br />DUE T0. OR AS A CONSEQUENCE OF <br />56. HOUR OF INJURY (24 Hn <br />59. PLACE OF INJURY -AT HOME. FARM. STREET, FACTORY. OFFICE <br />BLDG. ETC (Specify) <br />JP` <br />DUE TO OR AS A CONSEQUENCE OF T� \,J\ ` <br />181 6_6 (D ► 1 _" \'4 A- W� `( `A'� ` A f <br />5T DESCPI E HOW INJURY OCCURRED <br />AUTOPSY? (Ye.. Nol <br />80 LOCATION- STREET OR RFD NO CITY/TOWN. STATE <br />INTERVAL BETWEEN ONSET <br />A140 DEATH <br />INTERVAL BETWEEN ONSET <br />AND DEATH <br />INTERVAL BETWEEN ONSET <br />AND DEATH <br />S3 WAS CASE REFERRED TO <br />MEDICAL EXAMINER OR COR <br />MF#'9f1 ='535 <br />62 DATE RECEIVED (Mo Day. 7 <br />APR 3 0 1 990' <br />DOH 110008 (Rev. 8189) (formerly DSHS 9.150) <br />R � r' �.f✓ ^,1, S0'' 51,J+'/^, j 4 , R'. <br />HIS IS A GERTIHE•D�CO 0 TH R;E,CRORID ON F11LE t-7<fT HN C ENTERAFO , R� i triLTH ST►AT CEE<R`TI'FI CO:PLE < 1 , 1rU ST HA!E <br />F.IIC AL�SDA <br />4 <br />4 <br />re <br />4 <br />4 <br />4 <br />4 <br />