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1. Legal Name First Middle Last Suffix <br />(Include AKAs if any) <br />Jane Burniston GARRISON <br />2. Death Date (MON Do vvvvl <br />July 3, 2009 <br />. ; 3. Sex (000) <br />Female <br />4a- Age - Lastemt,d <br />94 <br />4b. Under 1 Year <br />4c. Under 1 Day <br />5. Social Security Number <br />541 -48 -9139 <br />6. County of Death <br />Multnomah <br />Month s 'Days <br />flours irJtes <br />7. Birthdate (MON Do rYYY) <br />June 23, 1915 <br />8a. Birthplace (cayrrown. or County) <br />Gordon <br />8b. (State or Foreign Country) <br />Nebraska <br />9 Decedent's Education <br />Some College Credits <br />7 ° 10 Was Decedent of Hispanic Ongin? (Yes or No. a yes, specify l <br />". No <br />11. Decedent's Race(s) <br />White <br />12. Was Decedent Ever in Li Yea <br />U.S. Armed Forces? }4X No <br />( J <br />LL ,_ 13. Residence: Number and Street (e g.. 624 SE stn street, Apt. No. e) <br />14707 S. E. Mill Street <br />14. City/Town <br />Portland <br />_ <br />--. - : 15. Residence County <br />�: Multnomah <br />16. State or Foreign Country <br />Oregon <br />17. Zip Code + 4 <br />97233 <br />18. Inside City Limits? <br />KNSles 0 N ❑ Unknown <br />Z - .:° 19. Marital Status at Time of Death <br />4a . Widowed <br />20. Spouse's Name (« marred or widowed gme name prior to first marriage.) <br />George A. Garrison <br />>- 21. Usual Occupation (Indicate type of work done during most of working life. DO NOT 050 "RETIRED . "1 <br />' Nurse <br />22. Kind of Business /Industry (00 NOT USE COMPANY NAME.) <br />Hospital <br />Q W <br />IB : 23. Father's Name (First. Mdele. Last, sure ) <br />w James B. Brown <br />24. Mother's Name Poor to First Marriage (First, M iddle. Last) <br />Jane B. Beekman <br />a - -: - - 25. Informant's Name <br />g? Carolyn Coulter <br />26. Telephone Number <br />503) 762 -4841 <br />27. Relation to Decedent <br />Daughter <br />28. Mailing Address (Number a S) eel, citynown. state, Op + 4) <br />16555 SE Main St Portland, Oregon 97233 <br />O <br />O.: 29. Place of Death <br />W( Licensed Foster. Care Facility <br />30. Facility Name <br />Adela Borlovan <br />ca <br />' 31. Location of Death (G03 address.) <br />O 14707 S. E. Mill Street <br />r <br />32. City /Town or Location of Death <br />Portland <br />133. State <br />1 Oregon <br />34. Zip Code + 4 <br />97233 <br />35. Method of Disposition <br />Burial <br />38. Name and Complete Address of Funeral <br />Omega Funeral & Cremation <br />36. Place of Disposition (Name of cemetery, crematory. or other place) <br />Willamette National Cemeter <br />Facility (Number s street. cay)r tan, state. zip , 4) <br />223 SE 122nd Portland <br />37. Location <br />Portland <br />OR 97233 <br />Or .on <br />41. OR License Number <br />3753 <br />39. Date of Disposition (MON 00 YYW) <br />413,. Funeral Direc • ' nature - <br />�- -- - , - <br />42. Registrar' Signature <br />9 f�2°' tr - r - <br />43. Date Received (MON DD YYYY) <br />JUL 10 2009 <br />44. Local File Number <br />45. Record <br />Amendment <br />_? 46. Was case referred to Medical Examiner? <br />❑ Yes /Oar <br />47. Autopsy? <br />❑ Yes kb0o <br />48. Were autopsy findings available to complete the cause of death? <br />❑ Yes 0 No <br />49. Time of Death <br />1005 <br />CAUSE OF DEATH (See instrucdonp and examples.) <br />50. Enter the chain of events - diseases, injuries, or complications - that directly caused the death. DO NOT ENTER TERMINAL EVENTS such <br />as cardiac arrest, respiratory arrest or ventricular fibrillation without showing the etiology. DO NOT ABBREVIATE. <br />Approximate Interval: <br />Onset to Death <br />l . t om . <br />Y / <br />'�, <br />Final disease or condition <br />resulting in deaths <br />w Sequentially list conditions, if any, <br />W - <br />tL leading to the cause listed on line a. <br />F. ENTER THE UNDERLYING <br />ce : ` 1 CAUSE LAST (disease or injury <br />that initiated the events resulting in <br />V :: death). l, <br />IMMEDIATE CAUS 4• p -� <br />a. vfl.U, \' $ j k <br />Due to (or as a consequence 9f) 4' <br />s <br />b. 0 n � I N <br />Due to (or as a consequence of) 4, , . J <br />c. n'.yr I n (..l VC (� L 1 F-"- <br />Due to (or as a consequence of) 4 t 1 r <br />d . <br />51. O ther s ia ant conditions contributing to death, putt not resulting in the underlying cause given above: <br />? sc SCOa0.60 C I^'oW & ( A�rv'a't Dl ��-' -- . <br />( � <br />W �- 52. .Mpnner of Death <br />2 i PrK.Naturat 0 Homicide <br />m -�( . 0 Accident ❑Undetermined <br />0 Suicide ❑ Pending <br />53. If remale <br />)(Not pregnant within past year 0 Not pregnant, but pregnant 43 days to 1 year before death <br />❑Pregnant at time of death ❑ Unknown if pregnant within the past year <br />0 Not pregnant but pregnant within 42 days before death <br />54. Did tobacco use contribute to death? <br />0 Yes 0 Probably <br />2.e. No ❑ Unknown <br />❑ <br />w 55. Date of Injury (Mon co rrvv) <br />�,... <br />56. Time of Injury <br />57. Place of Injury (e.g , Decedent's home, construction site, restaurant, wooded area) <br />58. Injury at Work? <br />❑ Yes ❑ No ❑ Unknown <br />J ` 59. Location of Injury (Number & Street City/Town, state. Z11 • 4) <br />a s <br />E 60. Describe how injury occurred. <br />0 0 <br />61. If transportation injury, specify. <br />0 Driver /Operator 0 Passenger 0 Pedestrian <br />0 Other (Specify) <br />Ili _ <br />CO :: 62. Name and Address of Certifier (Number & street. City/Town, State, zip • 4) <br />0 8 ■ •• • U • 0 :0 . . • •u • ' - •• . • • - ••. • • <br />. <br />1-- 63. Name and Title of Attending Physician if Other than Certifier <br />64. Title of Certifier <br />67. Medical Certifier - To the best of my knowledge, death o urred at the time. date, and <br />place, and due to the e(s) and manner stated. U <br />' 65. License Number p , ( `j/��� -- <br />, t he <br />) ti <br />66. Date Sign e31 hio rvvy„ ,tl <br />/ o�piinnionndeath <br />� in � /I sk�ation <br />68. Medical Examiner -On basis of examination, and/or t4 my <br />occurred at the time, date, and place, and due to the cause(s) and manner stated. <br />69. Record <br />Amendment <br />1t�t �tf <br />,Q j s, <br />:1110 <br />:11 <br />ORIGINAL - VITAL RECORDS COPY 45 -2 e ili'i <br />- ri_ <br />THIS IS A TRUE AND EXACT REPRODUCTION OF THE DOCUMENT OFFICIALLY • / - �/N n i e , <br />• REGISTERED AT THE OFFICE OF THE MULTNOMAH COUNTY REGISTRAR. , P r G! f 1 g % d fi <br />),,o LILA WICKHAM, AN MS ' ' - ` ' <br />> COUNTY REGISTRAR /j a <br />_.__ .__..- 11 11 1 A a')llf nnutTNCIMAH COUNTY. OREGON 4� , ,, - <br />TYPE OR <br />PRINT IN <br />PERMANENT <br />BLACK INK <br />550841 <br />201210380 <br />OREGON DEPARTMENT OF HUMAN SERVICES <br />CENTER FOR HEALTH STATISTICS 136 - <br />CER TI FICATE OF DEATH <br />STATE FILE NUMBER <br />THIS COPY IS NOT VALID WITHOUT INTAGLIO STATE SEAL AND BORDER. <br />