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Legal Name First Middle Last Suffix Galen Bryce Pearson Death Date December 13, 2006 Sex r Male - Birthdate 3 July 21, 1934 Age 72 years Y Social Security Number 544 -34 -3155 Count, of Death Jaccson Birthplace Kearney, Nebraska Was Decedent Ever in U.S. Armed Forces? Yes Q Residence: 3018 W 13th Street City/Town. Gran Island < Residence County CC W Hall State or Foreign Country Nebraska Zi Code + 4 6 Inside City Limits? Yes Z Marital Status at Time of Death Married Spouse's Name Prior to First Marriage Bobbie Lee Whiting } Father's Name 0° Clarence Herman Pearson Mother's Name Prior to First Marriage Zoa Fanny Fairchild ® Informant's Name w Bobbie L. Pearson Telephone Number Not Available Relationship to Decedent Spouse Mailing Address 3018 W 13th Street, Grand Island, NE 68803 it Place of Death 2 Hospital- Emergency Room /Outpatient Facil ty Name I Ashland Community Hospital O Location of Death yj yj 280 Maple St City/Town or Location of Death I Ashland State Oregon Zip Code + 4 1 9 p 7520 m Method of Disposition a Cremation Place of Disposition Litwiller- Slmonseln Crematory Location (City/Town and State) Ashland, Oregon Name and Complete Address of Funeral Facility Litwiller- Simonsen Funeral Home 1811 Ashland St, Ashland, Oregon 97520 Date of Disposition TBD Funeral Director's Signature r /S /.Melvin E (Friend OR License Number C0 - 3129 Registrar's Signature ■ /S /9fank,Collinsir. Date Received December 14, 2006 Local File Number 062042 Amendment Was case referred to Medical Examiner? Yes Autopsy? No Were autopsy findings available to complete the cause of death? Time of Death 03:02 AM W W LL ~ CAUSE OF DEATH IMMEDIATE CAUSE J a. atherosclerotic heart disease Approximate Interval: Onset to Death years Due to (or as a consequence of) y b. U Due to (or as a consequence of) 4 c. .-1 Q U W aal 2 >- -m = w W F Due to (or as a consequence of) 4 d. Other significant conditions contributing to death Manner of Death Natural If Female Did tobacco use contribute to death? Unknown Date of Injury _J Time of Injury Place of Injury 1 Injury at Work? a 0 U W Name 1- Location of Injury Describe how injury occurred and Address of Certifier James N Olson 4500 E Rogue Valley Hhway If transportation injury, specify. A, Central Point, Oregon 97502 Name and Title of Attending Physician if Other than Certifier Date Signed December 13, 2006 Medical Certifier /S/ James .TI ()Cron Title of Certifier M.D. License Number MD10050 Amendment ,, ,,,,,,,,,,,, ,Il nln �F , n II i, 1111111 III II1IIIIII I I 45-2CC (01/0 *20130214048* EAL17-i A , "' CERTIFICATION OF VITAL RECORD • < <.y^aes_ at..ti�':aa ^s_7 t:� tT's`r��E� a�S, :: '"�r,St? ?9v.a • ySS �' .,. .; • STATE OF OREGON 1eve.ayi:a N6S5:'��D'v`$"¢j > %i�'0'� '&Fr: soae'llp ALT ii OREGON HEALTH AUTHORITY H73848 CENTER FOR HEALTH STATISTICS CERTIFICATE OF DEATH I . TAG NO. 136- 2006 -0341 STATE FILE NUMBER I CERTIFY THATTHIS IS ATRUE, FULL AND CORRECT COPY OF THE ORIGINAL CERTIFICATE ON FILE OR THE VITAL RECORD FACTS ON FILE IN THE OREGON CENTER FOR HEALTH STATISTICS OR A DELEGATED LOCAL OFFICE. February 25, 2013 DATE ISSUED THIS COPY IS NOT VALID WITHOUT INTAGLIO STATE SEAL AND BORDER. • JEN A. V A, WOODWARD, Ph.D. STATE REGISTRAR 6 z