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. 0600412042 STATE OF ARIZONA DEPARTMENT OF HEALTH SERVICES - OFFICE OF VITAL RECORDS CERTIFICATE OF DEATH State File NO. 102.2012-022994 This is a true certification of the facts on file with the OFFICE OF VITAL RECORDS, ARIZONA DEPARTMENT OF HEALTH SERVICES, PHOENIX, ARIZONA. Revised 04/2010 PATRICIA ADAMS ASSISTANT STATE REGISTRAR This copy not valid unless prepared on a form displaying the State Seal and impressed with the raised seal of the issuing agency. 201403196 1. DECEDENT'S LEGAL NAME (FIRST, MIDDLE, LAST) 2. AKA'S (IF ANY) 3. DATE OF DEATH DOROTHY MAE ANSON JUNE 17, 2012 4. SEX 5. SOCIAL SECURITY NUMBER: 6. DATE OF BIRTH 7. AGE UNDER 1 YEAR UNDER 1 DAY 8. MONTHS . FEMALE 508 -60 -0859 03 -01 -1924 88 19 . DAYS 10 HOURS 111. MINUTES 12. PLACE OF DEATH - HOSPITAL: 13. PLACE OF DEATH - OTHER THAN HOSPITAL: • INPATIENT • E.R. /OUTPATIENT • DEAD ON ARRIVAL .... CARE FACILITY NURSING HOME OR LONGTERM RESIDENCE MI HOSPICE FACILITY MOTHER 14. FACILITY NAME (OR STREET ADDRESS IF NOT A FACILITY): 15. CITY, TOWN & ZIP GODS OR LOCATION OF DEATH. 16. COUNTY OF DEATH: 658 W WIGHT ST SUPERIOR 85173 PINAL 17. BIRTHPLACE (CITY AND STATE OR FOREIGN COUNTRY) 18.. MARITAL STATUS AT TIME OF 19. NAME OF SURVIVING SPOUSE (MAIDEN NAME IF WIFE) DEATH O'NEILL, NEBRASKA MARRIED WALTER MARVIN ANSON 20. DECEDENTS USUAL RESIDENCE STREET ADDRESS: 21. CITY AND COUNTY: 22. STATE 23. ZIP CODE 24. EVER IN THE ARMED FORGES 658 W WIGHT ST, SUPERIOR, PINAL ARIZONA 85173 NO 25 . WAS DECEDENT OF HISPANIC ORIGIN? 26. DECEDENT'S RACE(S). 27. I AMERICAN INDIAN OR ALASKA NATIVE. e§ NO, NOT SPANISH, HISPANIC OR LATINO WHITE AFRICAN p OTHER ASIAN (SPEC FY) SPECIFY UP TO 4 791)855 O YES, MEXICAN, MEXICAN AMERICAN, CHICANO ❑ BLACK, HAWAII AMEfl1CAN PRIMARY OR ENROLLED TRIBE 1:3 NATIVE NATIVE AN YES, PUERTO RICAN C:1 ASIAN INDIAN 0 YES, CUBAN ❑ CHINESE ❑ OTHER PACIFIC ISLANDER (SPECIFY) ADDITIONAL TRIBE ❑ YES, OTHER ( SPECIFY) O FILIPINO 13 JAPANESE 0 OTHER (SPECIFY) DI ❑ GUAMANIAN OR CHAMORRO ADTIONAL TRIBE. 0 UNKNOWN 0 KOREAN 26. OCCUPATION. ❑ VIETNAMESE I:1 UNKNOWN ❑ SAMOAN ADDIr10NAL TH3BE. HOMEMAKER AMERICAN INDIAN 091 ALASKA NATIVE 29. FATHER'S NAME (FIRST, MIDDLE, LAST) 30, MOTHER'S NAME (FIRST, MIDDLE, & LAST NAME PR1091 TO FIRST MARRIAGE) ROY COLE MAUDE ERNEST 31. INFORMANT'S NAME 32 RELATIONSHIP 33 INFORMANT'S MAILING ADDRESS: WALTER MARVIN ANSON SPOUSE 658 W WIGHT ST , SUPERIOR, ARIZONA 85173 34. NAME AND ADDRESS OF FUNERAL FACILITY: 35 FUNERAL 0)9150701. 36. LICENSE SUPERSTITION FUNERAL HOME 398 E. OLD WEST HIGHWAY APACHE NUMBER JUNCTION, AZ TIMOTHY J KROPP JR., FUNERAL DIRECTOR F1120 37. METHOD(S) OF Di5POS'TiON. 38. NAME AND LOCATION OF 131 DISPOSITION FACILITY 39 . NAME AND LOCATION OF 2nd DISPOSITION FACILITY CREMATION SUPERSTITION CREMATORY, APACHE JUNCTION, ARIZONA NONE MEDICA GE RTIFIcA TI ON S "CAUSE OF DEATH P ART 1 IMMEDIATE CAUSE 40 A 41 APPROXIMATE INTERVAL: OF DEATH CARDIORESPIRATORY ARREST UNKNOWN DUE TO OR AS A 42. B 43. APPROXIMATE INTERVAL CONSEQUENCE 0* DEMENTIA UNKNOWN DUE TO OR AS A 44. C 45. APPROXIMATE INTERVAL: CONSEQUENCE OF: Uilc 1 0 U+i A SA 40 . U 4T. AI-PHOXIn1Al£ INi01 -VAL CONSEQUENCE OF' CAUS O F DEAT P RT 11 46. OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING 49. INJURY? 50 INJURY AT WORK' 51. MANNER OF DEATH 52. TIME OF DEATH IN THE UNDERLYING CAUSES GIVEN ABOVE NO NO NATURAL DEATH 1736 PARKINSONS DISEASE, DEBILITY GASTRO ESOPHAGEAL REFLUX 53 WAS AN AUTOPSY PERFORMED' 54. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE THE CAUSE OF DEATH? DISEASE NO CAUSE A CS MA OF DEA CERTIFICATION Cei0e ng Physician/Nurse Practitionee'Physician's Assistant. - To the best of my 55. NAME OF PERSON COMPLETING CAUSE OF DEATH: 56. DATE CERTIFIED: knowledge, death occurred due to the cause(s) and manner stated. o andror i Medical nvesti Eaangatunerion,Tnin m Eat La y w 09-0100, Enforcedeath ment oc Authority curred at - tOn he tinge bases date 01 and exa place m natiat . due to the cause(s) and manner stated , . HECTOR SALAZAR, M.D. 06 -19 -2012 57. CERTIFdER'S ADDRESS: 58. NAME OF REGISTRAR: 59. DATE REGISTERED W 2005 HY 60 GLOBE, AZ 85501 KANDI HARRIS 06 -19 -2012 ; ANY ALTERATION OR ERASURE VOIDS THIS DOCUMENT Arizona Department of Health Services