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ANYAI_TERATION OR ERASURE VOIDS THIS DO( UMENI STATE OF ARIZONA DEPARTMENT OF HEALTH SERVICES - OFFICE OF VITAL RECORDS CERTIFICATE OF DEATH State File NO. 102- 2013- 015030 25. WAS D CEDENT OF HIS A IC ORIGIN? &I NO, NOT SPANISH, HISPANIC OR LATINO ❑ YES, MEXICAN, MEXICAN AMERICAN, CHICANO ❑ YES, PUERTO RICAN O YES, CUBAN ❑ YES, OTHER (SPECIFY) CE A NAME (FIST, ItpIDtl4 , LAST) l LL' S SR. 0 „UNKNOW 28 1 ; OCCUPA ( . F AT I I �"ba'FATHE 26. DECEDENT'S RACE(S): ® WHITE ❑ BLACK, AFRICAN AMERICAN ❑ NATIVE HAWAIIAN ❑ ASIAN INDIAN ❑ CHINESE ❑ FILIPINO O JAPANESE ❑ GUAMANIAN OR CHAMORRO D . KOREAN ❑;VIETNAMESE ❑ 'SAMOAN ❑ AMERICAN INDI ❑ OTHER ASIAN (SPECIFY) ❑ OTHER PACIFIC ISLANDER (SPECIFY) 27. IF AMERICAN INDIANOR ALASKA NATIVE. SPECIFY UP TO 4 TRIBES. PRIMARY OR ENROLLED TRIBE: ❑ UNKNOWN ALASKA NATIVE 0 . MOTHER'S NAME (FIRST, MIDDLE, & LAST NAME PRIOR TO FIRST MARRIAGE) ELIZABETH CARRAHE 31. I • RMANT'S NA M€ LORI DEVORE 32.RELATi DAUGHTER 34:_NAMEAND ADORES <OFFUNE° . L FACILITY: 35. FUNERAL DIRECTOR: 36. LICENSE MARIPOSA GARDENS MEMORIAL PARK & FUNERAL CARE 400 S. POWER NUMBER: ROAD, MESA, AZ VALORIESTADING, FUNERAL DIRECTOR F1375 3 . METHOD(S) OF DISPOSITION. 33. NAME AND LOCATION OF 1st DISPOSITION FACILITY: 39, NAME AND LOCATION OF 2nd DISPOSITION FACILITY: M MORTUARY MISSION CHAPEL & CREMATORY, ,REMA I * N MESA ARIZONA PF DEATH CADS DUE TO ORASA CONSEQUENCE OF: DUE TO ()RASA CONSEQUENCE OF: DUE TO OR AS A CONSEQUENCE OF: 51. MANNER OF DEATH 52. TIME OF DEATH NATURAL DEATH 0825 54 WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? HYPERTENSIVE CARDIOVASCULAR DISEASE 48. N THE SIGNIFICANT R CAUS ITIONS CO RIBUTINGTO DEATH =UT NOT RESULTING E $ GIVEN ABOVE. TES MELLITUS -TYPE 2 - YEARS. 33. IN • ° MAN 'SMAILIN ADD -ESS: 2347 S ZINNIA MESA, ARIZONA 85209 41. APPROXIMATE INTERVAL: YEARS 43. APPROXIMATE INTERVAL; 45. APPROXIMATE INTERVAL: 47. APPROXIMATE INTERVAL: 1. DECEDENT'S LEGAL NAME (FIRST, MIDDLE, LAST) JOHN JOSEPH GILLESPIE JR 4. SEX 5. SOCIAL SECURITY NUMBER: MALE 505 -52- 7590 12. PLACE OF DEATH - HOSPITAL: , INPATIENT Q ER./OUTPATIENT ❑ DEAD ON ARRIVAL 141 FACILITY NAME (OR STREET ADDRESS IF NOT A FACILITY): 2347 S ZINNIA 17. BIRTHPLACE (CITY AND STATE OR FOREIGN COUNTRY) TILDEN, NEBRAS 20. DECEDENT'5 US RESIDENCE STREET ADDRESS: 2347SZi; 'A Certifyyii Physician/Nurse Practitioner/Physician's Assistant - To the best of my knowledge, death occurred dueto the cause(s) and manner stated. �- Medical Examiner/Tribal Law Enforcement Authority - On the basis of examination, and /or investigation, in my opinion,; death occurred at the time, date, and place, and due to the cause(s) and manner stated. 57 CERTIFIERS ADDRESS: 202 E EARLL DR PHOENIX. AZ 85012 13. PLACE OF DEATH - OTHER THAN HOSPITAL: CARET ACHOME OR LONG TERM ® RESIDENCE Q HOSPICE FACILEFY ['OTHER ILITY I—I 15. CITY, TOWN & ZIP CODE OR LOCATION OF DEATH: MESA 85209 18. MARITAL STATUS AT TIME OF DEATH: WIDOWED NAME OF SURVIVING SPOUSE (MAIDEN NAME IF WIFE) APRIL 02, 2013 UNDER 1 DAY 11. MINUTES STATE OF ARIZONA 20130421” WILLIAM BUNTING, MD 58. NAME OF REGISTRAR: MICHELE CASSTANE$AaMARTINEr This is a true certification of the facts on file with the OFFICE OF VITAL R CORE"' ` ARIZONA DEPARTMENT OF HEALTH SERVICES, PHOENIX, ARIZONA. S SIST T 4 ER GI ASSIST/41 STAr REGISTRAR Revised 04/2010 This copy not valid unless prepared on a form displaying the State Seal and impressed with the raised seal of the issuing agency. 59.DATE REGISTERED 04/16/2013 CERTIFICATION OF VITAL RECORD