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CERTIFIED C
<br />Tn
<br />r1
<br />0
<br />6ECEASED
<br />PARENTS
<br />CAUSE
<br />BURIAL '-
<br />FATHER -NAME
<br />IS.
<br />CERTIFICATION--
<br />PHYSICIAN:
<br />1 ATTENDED THE
<br />21,1. DECEASED NOM
<br />FIRST
<br />JOSEPH EDWARD DUNN
<br />MONTH
<br />DAY
<br />YEAR
<br />MIDDLE
<br />MONTH
<br />TO
<br />216.
<br />DAY
<br />76e.
<br />YEAR
<br />(AST
<br />AND 1AST SAW HIM /HER ALIVE ON
<br />MONTH DAY YEAR
<br />21T.
<br />THE
<br />1 DID /DID NOT VIEW THE
<br />SOOT AFTER DEAIN.
<br />21d
<br />EPH 20
<br />LAS•
<br />0
<br />00
<br />7G
<br />0
<br />E/)
<br />w
<br />0.
<br />TYPE, OR PRINT IN
<br />PERMANENT INK
<br />SEE HANDBOOK FOR
<br />INSTRUCTIONS
<br />USUAL RESIOENCe
<br />WHERE DECEASED
<br />LIVED. IF DEATH
<br />OCCURRED 104
<br />INSTITUTION, GIVE
<br />RESIDENCE BEFORE
<br />ADMISSION.
<br />r
<br />(OCAI F1*! NUMBER
<br />DECEASED - NAME
<br />RACE WHITS; NEGRO, AMERICAN INDIAN,
<br />ETC. ( SPECIFY 1
<br />WHITE
<br />CITY, TOWN, OR LOCATION OF DEATH
<br />T6 FREDERIKSTED
<br />STATE OF BIRTH If NOT IN U.S.A., NAME
<br />0. NEBRASKA
<br />SOCIAL SECURITY NUMBER
<br />12 506 -66 -5322
<br />RESIDENCE -STATE
<br />14o S T. CROIX
<br />INFORMANT -NAME
<br />PART 1.
<br />10
<br />CONDITIONS, IF ANY,
<br />WHICH OAVE RIS! 10 (b)
<br />IMMEDIATE CAUSE 101,
<br />STATING THE UNDER -
<br />LYING CAUSE LAST
<br />(c)
<br />INJURY AT 'WORK
<br />1 SPECIFY YES OR N0I
<br />20s.
<br />201
<br />EIRST
<br />VIRGIN ISLANDS OF THE UNITED STATES
<br />1
<br />WILLIAM FRANCIS
<br />COUNTRY 1
<br />COUNTY
<br />VI
<br />146.
<br />IMMEDIATE CAUSE
<br />201.
<br />AGE-LAST
<br />BIRTHDAY (YEARS
<br />so. 62
<br />DEATH WAS CAUSED BY,
<br />PART 11. OTHER SIGNIFICANT CONDITIONS:
<br />CANCER
<br />ACCIDENT, SUICIDE, HOMICIDE,
<br />OR UNDETERMINED (seem
<br />20e. NATURAL
<br />JOHN CONINGHAM
<br />CITIZEN OP WHAT COUNTRY
<br />9
<br />U$
<br />CERTIFIER -NAME 01'! on PRINT(
<br />23s. FRANCISCO J. LANDRON MD
<br />DEPARTMENT OF HEALTH
<br />CERTIFICATE OF DEATH
<br />UNDER 1 YEAR
<br />HOS. I DAYS
<br />Sb
<br />NSIDE CITY UNITS
<br />1 00EC1FY YES OR NO
<br />7s.
<br />USUAL OCCUPATION lave RING OF WORK DONE DURING mow or
<br />WORKING LIFE, EVEN IF RETIRED 1 E
<br />13o. DITOR -
<br />CITY, TOWN, OR LOCATION
<br />FREDERIKSTED
<br />14L.
<br />Po MULTIPLE ORGAN FAILURE
<br />but /0, OP AS A CONSEQUENCE Oft
<br />DUE TO, OP AS A CONSEQUENCE OE:
<br />DATE OF INJURY I MONTH. DAY, YEA! 1
<br />PLACE OF INJURY AT HOME, FARM, STREIT, PAC/01Y,
<br />OFFICE SLOG., EEC. 1 SPECIFY : 3i
<br />CERTIFICATION - MEDICAL EXAMINER OR CORON RE Om we BASIS OF THE
<br />EXAMINATION OF THE BOGY A140 /011 THE INVESTIGATION, IN MY OPINION,
<br />DEATH OCCURRED ON ME DATE AND DUE 10 TNe CAUSEIS) STATED.
<br />220.
<br />MIMIC
<br />UNDER 1 DAY
<br />HOURS
<br />s<.
<br />MARRIED, NEVER MARRIED,
<br />WIDOWED, DIVORCED 1 sremIF , 1
<br />1B. MARR•I-
<br />HOUR
<br />201.
<br />LOCATION
<br />206
<br />MM,
<br />HOUR OF DEATH
<br />DUNN
<br />LAST
<br />SEX
<br />MALE
<br />DATE OF BIRTH , MONTH, DAY,
<br />YEAR I
<br />6. AUG. 8, 1951
<br />M.
<br />20d.
<br />M.
<br />11.
<br />MOTHER - MA DEN NAME
<br />(ENTER ONLY ONE CAUSE PER LINE FOR (D(, (6), AND (c))
<br />CONDITIONS CONTRIBUTING TO DEATH BUT NOT 0E(ATEO 10 CAUSE GIVEN /N RAM I lel
<br />SEATS FILT NUMBER
<br />DATE OF DEATH I MONTH, DAY, YEAR 1
<br />3. JANUARY 18, 2014
<br />COUNTY OF DEATH
<br />i e. ST. CROIX
<br />HOSPITAL OR OTHER INSTITUTION -NAME 11E pros IN EITHER, GIVE SWIM AND NUMBER
<br />76. #156 CONCORDIA WEST
<br />SURVIVING SPOUSE 11MW1EE, GIVE MAMEN NAME 1
<br />BARBARA DUNN__ _
<br />KIND OF BUSINESS OR INDUSTRY
<br />13b DAILY NEWS. PAPER
<br />INSIDE CITY LIMITS STREET AND NUMBER
<br />'snort YES OR NO 1
<br />14a. ) 4, #156 CONCORDIA WEST
<br />EIRST MIDDLE
<br />PHYLLIS C. SCHROEDER
<br />16.
<br />MAILING ADDRESS (STREET OR R.T.D. NO. CITY 00 00444, STATE, 0E1
<br />I P.O. Box 2015 FREDERIKSTED, ST. CROIX 00841
<br />HOW INJURY OCCURRED I ENDER NATURE OE 1 1 OR PART II, IQ.
<br />1 STREET 00 0,1.0. N0„ VW OR TOWN, S1AEE 1
<br />DECEDENT WAS PRONOUNCED DEAD
<br />M TN DAY 0440
<br />226 JANUARY
<br />SIGNATURE DEGREE OR TIT
<br />236, /S/ FRANCISCO J. LANDRON MD
<br />AP►RORIMAIE INTERVAL
<br />ETWEEN ONSET AND DFAtu
<br />HOUR
<br />,BI
<br />AUTOPSY IF YES WERE /1NDINGS COT.
<br />1010 CM 1401 SIDEBED IN OFTERM1N1N0 CA:1SE
<br />LEE
<br />No ° "'" No
<br />ININRY PA0?
<br />DEATH OCCURRED Al ENE Euc1, o.: Tut
<br />(HOUe? DATE, AA.D, TO :NT SW
<br />OF MT RNOw11500, Dv!
<br />21s. M TO THE CAUSEIBI STATED
<br />18 2014 6:33 A M
<br />DATE SIGNED 1•0N1•, DAY VFARI
<br />72[ JANUARY 21, 201
<br />MARINO ADDRES - CERT ER E OR R.F.D. N. CITY OR TOWN I
<br />23a. bOV. JUAN 1 . LUIS HOSPITAL 400 IJ IAMOND RUBY CHRISTIANSTED ST6' CROIX U.S• I. 0082
<br />BURIAL, CREMATION, REMOVAL CEMETERY OR CREMATORY --NAME TOCATION em oR TOWN 811118 1 B►etln T REMOVAL NEBRASKA NEBRASKA 24a. 216. 4D.
<br />DATE 1 MGN Eyy,, AY , FUNERAL HOME NAME AND ADDRESS 1 OR . , C1?Y OR TOWN. STATE ZIP 1
<br />T ea. .JANUARY L3 2114 no. DIVINE FU c_` � PETER'S ' V I 00823
<br />FUNERAL DIRECTOR - SIGNATURE S RVICES, Ll 1Z9 PETER S REST , C STED • •
<br />REGISTRAR - SIGNATURE RECEIVED SY LOCAL REGISTRAR
<br />2 Sb• / DON E. REY ISI .SONIA NAVARRO - JO 1
<br />
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