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..... 20160011g STATE OF ARIZONA 201101127 44 C 45 Date Issued: 01-26-2011 STATE OF ARIZONA DEPARTMENT OF HEALTH SERVICES - OFFICE OF VITAL RECORDS CERTIFICATE OF DEATH 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 55 NAME OF PERSON COMPLETING c‘yse OF DEATH KENNETH C. CABLE, M.D. 58 NAME OF REGISTRAR - MICHELE CASTANEDA-MARTINEZ 47 APPPflICIMATE INTFPVAL aixd— PATRICIA AqAMS ASSISTANT STATE REGISTRAR This copy not valid unless prepared on a form displaying the State Seal and impressed with the raised s agency. 1 DECEDENT'S LEGAL NAME (FIRST, MIDDLE, LAST) RICHARD D DEVORE 4 SEX MALE 5 SOCIAL SECURITY NUMBER 505-36-7744 12 PLACE OF DEATH - HOSPITAL 0 INPATIENT 0 E 11 /OUTPATIENT 0 DEAD ON ARRIVAL 14. FACILITY NAME 1011 011111111 ADDRESS IF NOT A FACILITY). 1825 E EMELITA AVE #502 17 BIRTHPLACE (CITY AND STATE OR FOREIGN COUNTRY) OOD RIVER, NEBRASKA 20 DECEDENT'S USUAL RESIDENCE STREE r ADE,HEbs. 047 S SCHAUPPSVILLE RD, 21. Gi AND COS Titrit. WOOD RIVER, HALL 2 2 sr,' ATE NEBRASKA 27 ZIP CODE 68883 25 WAS DECEDENT OF HISPANIC OR/GIN7 It% NO, NOT SPANISH, HISPANIC OR LATINO CI YES, MEXICAN, MEXICAN AMERICAN, CHICANO 0 YES, PUERTO RICAN 0 ‚(115, 0015511 0 YES, OTHER (SPF.CIF Y1 11 UNKNOWN 25 0CC1JPATION FARMER 29 FA.THER'S NAME (FIRST, MIDDLE, LAST) MAURICE D DEVORE 31 INF ORMANT'S NAME PATRICIA ANN DEVORE 34 NAME AND 5001111502 011 FUNERAL FACILITY MELCHER MORTUARY MISSION CHAPEL & CREMATORY 6625 EAST MAIN STREET MESA, AZ 37 MET I-100;S) OE DISPOSITION CREMATION MEDI AL ERTIR :11*N t 4 44 'E • DEATtl PART 1 IMMEDIATE CAUSE OF DEATH th.JE r C.) OR AS A CONSEQUENCE OF CUE TO OR AS A CONSEQUENCE 01- l00, CONSEQUENCE OF' AU la .F DEATH PAftt 44 OTHER SIGNIFICANT CONDITIONS CONTRIBUTING 10 DEATH BUT NOT RESULTIN IN THE UNDERLYING CAUSE 5 G/VEN ABOVE Certitying Physician/Nurse Practitroner/Physician's Assistant- To the best of my knowledge, death occurred due to the cause(s) and manner stated In Method' ExammenToGal Law Enforcement Aukhoitty - On the basis 01 examination, and/or investigation, in my opinion, death occurred at the time, data and place, and due to the cause(s1 and manner stated 57 CERTIFIER'S ADDRESS: 13620 N. 55TH AVE. GLENDALE, AZ 85304 8.47esa 6 DATE OF BIRTH 11-27-1931 se NAME AND LOCATION OF 1 st DISPOSITION FACILITY MELCHER MOFITUARY MISSION CHAPEL & CREMATORY, MESA, ARIZONA 2 AKA'S BF ANY) 7 AGE 79 B. MONTHS 13 PLACE OF DEATH - 012-41111 111514 HOSPITAL rn NURSING HOME OR LONG TERM r.-1 0 VISTA SENIOR LIVING L.-1 CARE FACILITY uRESIDENCE 0 HOSPICE FACILITY 15. MARITAL STATUS AT TIME OF DEATH MARRIED 32.RELATIONSHIP SPOUSE UNDER 1 YEAR 15. CITY, TOWN & ZIP CODE OR LOCATION Of DEATH, MESA 85202 26. DECEDENT'S RACE(SI IN WHITE 0 BLACK, AFRICAN AMERICAN 0 NATIVE HAWAIIAN 0 451411 11101414 0 CHINESE FILIPINO 0 JAPANESE 0 GUAMANIAN OR CHAMORRO 01 KOREAN C3 VIETNAMESE 0 UNKNOWN 0 SAMOAN p AMERICAN INDIAN OR ALASKA NATIVE 0 OTHER ASIAN (511110 1133 0 OTHER PACIFIC ISLANDER (SPECIFY) 0 OTHER {SPECIFY) 30 MOTHER'S NAME (FIRST, MIDDLE, & LAST NAME PRUR700111131 IVIARHIAGE) HELEN L MAILANDEF1 40 A CHRONIC OBSTRUCTIVE PULMONARY DISEASE 42 13 TOBACCO USE iNrosmANT s MAILING 5001111 1515 6047 S SCHAUPPSVILLE RD , WOOD RIVER, NEBRASKA 68883 35 FUNERAL oifiscropt VALORIE STADING , FUNERAL DIRECTOR 45 9 NO 9 DAYS t1' State File NO. 102-2011-001683 3 DATE OF DEATH ANUARY 09, 2011 UNDER 1 DAY 10 HOURS 11. MINUTES 16 COUNTY OF DEATH MARICOPA 19 NAME OF SURVIVING SPOUSE (MAIDEN NAME IF WIFE) PATRICIA ANN COOPER 50 1133117 51 VVORIO NO WAB AN ALI PERFORMED NO 51 MANNER OF DEATH NATURAL DEATH 27 IF AMERICAN NINDIAN 09 A LABgA NATIVE 55 504117 OP TO 4 TR15E5 PRIMARY 09 51111(30,110 711585 ADDITIONAL TRIBE 50017101150 175155 AtiPtritinAt 5I6(55 24 EVER IN THE ARMED FORCES YES 36 LICENSE NUMBER F1375 39 tiAms AND LOCATION OF 224 DISPOSITION FACILITY NONE 41 APPROXIMATE INTERVAL' YEARS 43 APPROXIMATE INTERVAL. YEARS 45. APPROXIMATE INTERVAL 52. TIME OF DEATH 0647 54 WERE AU IC PSY 11 AVAILABLE 70 COMPLETE THE CAUSE OF DEATH AU AND MANNER OF DEATli TI*N 56 DATE CERTIFIED. 01-12-2011 59 DATE REOISTE RED 01-21-2011 CERTIFICATION OF VITAL RECORD ANY ALTERATION OR ERASURE VOIDS THIS DOCUMENT , or) 145471, / Aritona Department of Health Services