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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.
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