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"VERIFICATION BOX" (HOLD BETWEEN THUMB AND FOREFINGER, OR BREATHE ON IT. COLOR WILL CHANGE TO BLUE AND THEN RETURN.) <br />STATE OF ARIZONA <br />DEPARTMENT OF HEALTH SERVICES - OFFICE OF VITAL RECORDS <br />CERTIFICATE OF DEATH <br />DESCRIBE HOW INJURY OCCURRED <br />DEATH NO. <br />D-1022007. O '3504, <br />WAS DECEASED EVER IN U.S. ARMED FORCES? <br />(SPECIFY YES OR NO) <br />5. NO <br />TION AND /OR INVESTIGATION, IN MY OPINION DEATH OCCURRED <br />AND LACE DUE TO THE CAUSE(S) AND MANNER STATED. <br />May 3,2007 <br />This is a true certification of the facts on file with the OFFICE OF VITAL RECORDS, r <br />tCiiICIA "ADg S • ARIZONA DEPARTMENT OF HEALTH SERVICES, PHOENIX, ARIZONA issued under � 1S Si STT ILTE'REGISTRAA r r r } <br />the authority of A.R.S. 36 -341, and by direction of <br />This copy not valid unless prepared on a form displaying the State Seal and impressed with Vise4 oft e lSsdi ^• ,- <br />60. <br />❑DOA <br />❑ OP EMER. <br />❑ IN PATIENT <br />(IF WIFE, GIVE MAIDEN NAME) <br />HOUR OF DEATH <br />36. <br />PRONOUNCED DEAD (Hour) <br />36. AT <br />RACE (e.g., white, black, American Indian, (specify tribe)etc. <br />SPECIFY: <br />4A. WHITE <br />STATE AND (9 not in USA, name country) <br />CITY OF BIRTH <br />11 NEBRASKA, PETERSBURG <br />BURIAL, CREMATION, <br />REMOVAL, OTHER (Specify) <br />24. CREMATION <br />MANNER OF DEATH <br />❑ NATU SES ❑ HOMICIDE <br />CAURAL <br />❑ ACCIDENT ❑ PENDING <br />INVESTIGATION • <br />❑SUICIDE ❑UNDETERMINED <br />WAS DECEDENT OF HISPANIC ORIGIN: <br />(SPECIFY YES OR NO) <br />46. NO <br />INSIDE CITY OMITS? <br />(SPECIFY Yes or No) <br />15F. YES <br />ON RESERVATIONS <br />(SPECIFY Yes or No) <br />15G, NO <br />26.ALL STATE <br />TO THE BEST OF MY KNOWLEDG <br />DUE TO THE CAUSE( • AT <br />30. SIGNATURE <br />AND TITLE <br />NAME OF ATTENDING • SICIAN OF OTHER THAN CER <br />33. <br />NAME AND ADDRESS OF CERTIFIER, PHYSICIAN, MEDICAL EXAMINER OR TRIBAL LAW ENFORCEM ^ AUTHORITY ' ; AUTHOR IZED� O CREE <br />°r 3' p tMIS NP 1510 E FLOWER ST : AZ 8 0 ..4 °'" , chary 4xea ❑N <br />D 4�PR EGI 2 d l 43.G. F8 3 7 4 44. r RAR'S SIG r / •� / I� <br />47A. IMMEDIATE CAUSE (FINAL DISEAS• OR OND ON SULTING IN DEATH) (ENTER ONLY ONE el SE ON EACH UN ) <br />PART 11. Other significant conditinns contributing to death but not resulting in the underlying cause given In Part I <br />PLACE OF INJURY (At home, farm, street, factory, office building, etc.) <br />SPECIFY <br />56. <br />IF YES, INDICATE MEXICAN, SPANISH, PUERTO RICAN, <br />CUBAN, ETC. <br />4C. <br />6C. HOSPITAL OR (IF RESIDENCE GIVE STREET ADDRESS) <br />INSTITUTION <br />2347 S ZINNIA <br />MARRIED, NEVER MARRIED, <br />WIDOWED, DIVORCED (SPECIFY) <br />g. MARRIED <br />852.09 <br />PREVIOUS STATE <br />OF RESIDENCE <br />16. NEBRASKA <br />USUAL OCCUPATION (Give kind of work <br />done most of working life, even If retired) <br />14A. HOMEMAKER <br />16�� 3.. YEARS <br />ANY AI If RATION O1! E10St1RE VOIDS IH14 I)0( UME -NT 1 <br />11(1314'1 <br />