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1. Decedent's Legal Name (First Middle, Last) <br />CAROLYN E. ; .WILSON <br />6. Last Name Prior to First Marriage.;: <br />CORpEI <br />;Oa. Place 0rflea <br />rst* HOME <br />10e. City or Town Of Death <br />PRAIRIE'VILLAGE <br />13b. State or Foreign Country •• : 13c6 County or Province <br />KANSAS I0 N. SQ.N <br />14. Decedent's Ancestry <br />GERMAN WHITE <br />15. Decedent's Hispanic Origin <br />NOT SPANISH' - HISPANIC `LATINO <br />17. Dete eries 'Education <br />HIGH; SCHOOL'GRADUATE OR GED CO?NIPLETED <br />20. Father /Parent Birth Name (Fir $t, Middle, Last). <br />GEORGE CORDEL <br />2a Informant's Name (First Middle Last) 22b. MeiUng Address (Street .Number, City, State; And Zip Lode) <br />KENT WILSON x}123 W 74TH TERR, PRA <br />RAIRIE VILLAGE ; KANSAS, 66 <br />23. Mettlod Of Disposition 24a.. Place 0# Disposuion. . <br />CREMATION:. :PORTER CREMATORY <br />25. Funeral :Service LUtenseeAnd License Number ` 26. Name .QfEnibafnler.And License Number <br />/5 /)EANNt11E S FORD 2946 NOT EMBALr4ED = 9999 <br />27. Name: And AddresS.Of Firm CREMATION SOCIETY OF XS AND MO, 8837 ROE AVENUE, PRAIRIE VILLAGE, KANSAS 66207 <br />28. Cause Of Death <br />Part I. Events s( diseases, inunes, or <br />IMMEDIATE CAUSE (Finaf <br />Disease. Or Condition Resulting <br />In Death) • <br />Conditions, if any, leading <br />To cause listed on a. <br />UNDERLYING CAUSE (disease <br />or injury that initiated the <br />events resulting in death) <br />LIST'ED LAST <br />Part 11. Other; Significant Condition] <br />30. Did Tobacco Use Contribute To Death? <br />33a. Date Of Injury (Month Day, )!ear) <br />33e. Place Of Injury <br />34a. Date Pronounced Dead (Month, DO} <br />06/20/2016 <br />35a. Pronouncing and Certifyaiag Physician' <br />/5/DONALD COHEN - DO <br />complicationS) that directly caused the d eath:: <br />a METASTATIC OVARIAN CANCER <br />Due To(Or As A Consequence Of): <br />1. Manta( Status <br />WIDOWED' <br />Contributing To Death But Not Resulting In The Underlying Cause Given In Part I. <br />7a Of Birth <br />01/16/1938 <br />Kan$as'Departn ent of`Health anal Ertvirartme t <br />Office of Vital Statistics <br />CERT FItATE QF DEATH <br />Dale To (Or M A Consequence 90: <br />34b. Time Pronounced Dead <br />12:30 AM <br />35b. License No. <br />518512 <br />VS231A - Rev. 07/0112009 <br />Death 6 /28/2016 V210189476 01 WILSON 20160401141210c <br />1Db., Facility Name (If Not Institution, Street And Number) <br />BRIGHTON GARDENS <br />13d. City or Town <br />PRAIRIE VILLAGE: <br />16. Decedent's Race <br />Due To (Or As A Consequence Of): <br />31. If Female: <br />NOT PREGNANT WITHIN THE PAST YEAR <br />35c. Date Certified <br />06/21/2016 <br />3. Date Of Death (Month; Day, Year):: <br />£16/20/2016 513 -42 -2298 <br />8. Place Of Birth (City And State Or Foreign Country) <br />'BURR OAKS, KANSAS <br />12.: 6urviving Spouse (Name Prior to First Marriage) <br />29a, Autopsy <br />NO <br />33f. Locatiorr (Street And Number Or Rural Route, <br />34c. Actual Or Presumed lime Of Dear <br />4. Social Security Number <br />City Or Town, State, And Zip: Code) <br />• <br />13a. Residence - Street Address <br />4123 W 74TH TERR <br />13e. Zip Code <br />66208 <br />21. Mother(Parent Birth. Name (First, Middle, Last) <br />19. Decedent's Industry. <br />PHOTOGRAPHY <br />22c. Relationship. To Decedent <br />SON <br />29b. Autopsy Findings Available <br />To Complete The Cause Of Death <br />Approximate Interval: <br />Onset To Death <br />32. Manner Of Death <br />NATURAL <br />34d. Name Of Person Pronouncing Death <br />5. Date filed By State Registrar <br />06/24/2016 <br />9. Decedent Ever In U.S Armed Forces <br />NO <br />13f. Inside City Limits <br />YES <br />34e. License No. <br />35d. Address A: Zip Code DfPerson Completing Cause Of Death <br />5701 W 119TH ST STE 419, OVERLAND PARK, KANSAS, 66209 <br />