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OF VITAL RECORD
<br />T DEE
<br />CE�L�IJXXG�Aq6QSg TAT F2 (1F VITAL STATISTICS TFYAC CERTIFICATE OF DEATH STATE FILE NUMBER 142-17-114327
<br />EDR OF STATE HEALTH SERVICES
<br />1. LEGAL NAME OF DECEASED (Include AKA's, 6 any) (First, Middle, Last) (Maiden) 2. DATE OF DEATH - ACTUAL OR PRESUMED
<br />(mm- dd -yyyy)
<br />MARGARET ANN ENEVOLDSEN I LONGMAN AUGUST 5, 2017
<br />3. SEX 4. DATE OF BIRTH (mmdd -yyyy) 5 AGE -Last Birthday... IF UNDER 1 YR IF )IINDFR DAY 6. BIRTHPLACE (City /& State or Foreign Country)
<br />(Years) Mo Days ours Min
<br />FEMALE JULY 5, 1934 83 OMAHA, NE
<br />7. SOCIAL SECURITY NUMBER 8. MARITAL STATUS AT TIME OF DEATH co Married 9. SURVIVING SPOUSES NAME (Ii wife, give name prior to first mamage)
<br />❑ Widowed ❑ Divorced ❑ Never Married ❑ Unknown
<br />483 -34 -1207 ANDREW MILTON ENEVOLDSEN
<br />10a. RESIDENCE STREET ADDRESS 10b. APT. NO. 10c. CITY OR TOWN
<br />2322 FM 876 WAXAHACHIE
<br />tDd. COUNTY 10e. STATE - -- 101. Z P CODE 10g. INSIDE CITY LIMITS?
<br />[3 Yes ® No
<br />ELLIS TEXAS 75167
<br />it. FATHERS NAME PRIOR TO FIRST MARRIAGE 12. MOTHER'S NAME PRIOR TO FIRST MARRIAGE
<br />WILLIAM H. LONGMAN LUCILLE MCQUILKIN
<br />13. PLACE OF DEATH (CHECK ONLY ONE)
<br />IF DEATH OCCURRED IN A HOSPITAL: IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL
<br />❑ Inpatient ❑ ER/Outpatient ❑ DOA ❑ Hospice;Facd6 ❑
<br />y .Nursi Home El Decedents Home '❑ Other (Specify)
<br />14. COUNTY OF DEATH 15. CITY/TOWN, ZIP' (IF OUTSIDE - CITY LIMITS, GIVE PRECINCT NO) 16. FACILITY NAME (It not institution, give street address)
<br />ELLIS PRECINCT 2, 75167 2322 FM 876
<br />17. INFORMANT'S NAME & RELATIONSHIP TO DECEASED 18.. ADDRESS OF INFORMANT (Street and Number,City,State,Zip Code)
<br />CHRIS HANSEN - DAUGHTER 2322 FM 876, WAXAHACHIE, TX 75167
<br />19. METHOD OF DISPOSITION 20 SIGNATURE AND LICENSE NUMBER OF FUNERAL DIRECTOR OR PERSON 21. ®Unknown
<br />El Burial ® Cremation ❑ Donation - ACTING AS SUCH
<br />❑ Entombment ❑ Removal from state Section
<br />RONNY LANGFORD ,BY ELECTRONIC SIGNATURE -
<br />❑ Other (Specify)
<br />114296 Block
<br />22. PLACE OF DISPOSITION (Name of cemetery, crematory, other place) - 23. LOCATION (City/Town. and Slate) Lot
<br />CREMATION CARE WAXAHACHIE, TX Space
<br />24. NAME OF FUNERAL FACILITY - 25. COMPLETE ADDRESS OF FUNERAL FACILITY (Street and Number, City, State, Zip Code)
<br />BOZE- MITCHELL- MCKIBBIN FUNERAL HOME - WAXAHACHIE 511 W. MAIN STREET, WAXAHACHIE, TX 75165
<br />26. CERTIFIER (Check only one)
<br />3 Cesfying physician -TO the best of my knowledge, death occurred due to the muscle) and mane r stated.
<br />▪ Medical Examiner/Justice of ins Peace - On the oasis of examination, and/or investigation, in my opinion, death occuned at the ame,date and place, and due to me cause(s) and manner stated.
<br />27.SIGNATURE OF CERTIFIER - - 28. DATE CERTIFIED (mmdd -y W( 29.LICENSE NUMBER 30. TIME OF OEATH(Actual or presumed)
<br />JOE L PERRYMAN III, BY ELECTRONIC SIGNATURE : AUGUST 8, 2017 K5376 04:02 AM
<br />31. PRINTED NAME, ADDRESS OF CERTIFIER (Street and Number, Ciy,State Z p Code) 32. TITLE OF CERTIFIER
<br />JOEL PERRYMAN III 400 W ARBROOK STE 100, ARLINGTON, TX 75219 MD
<br />33. PART 1. ENTER THE CHAIN OF EV NTS - DISEASES, INJURIES; OR COMPLICATIONS - THAT DIRECTLY CAUSED THE DEATH. DO NOT ENTER Approximate interval
<br />TERMINAL EVENTS'SUCH AS CARDIAC ARREST, RESPIRATORY ARREST, OR VENTRICULAR FIBRILLATION WITHOUT SHOWING THE Onset to death
<br />ETIOLOGY. DO NOT ABBREVIATE. ENTER ONLY ONE CAUSE ON EACH.
<br />IMMEDIATE CAUSE (Final
<br />disease or condition
<br />resulting in death) a. MYELODYSPLASTIC SYNDROME MONTHS
<br />Due 10 (or as a consequence of):
<br />Sequentially list conditions,
<br />if any, leading to the cause b. NON ST ELEVATED MYOCARDIAL INFARCTION DAYS
<br />listed on line a. Enter the
<br />UNDERLYING CAUSE Due to (or as a consequence of):
<br />(disease or injury that
<br />initiated, the events resulting
<br />death) eath ath) LAST a
<br />Due to (or as a consequence el(.
<br />PART 2. ENTER OTHER SIGNIFICANT CONDITIONS CONTRIBUTIN T DEATH BUT NOT RESULTING IN THE UNDERLYING 34. WAS AN AUTOPSY PE FORMED?
<br />CAUSE GIVEN IN PART L ❑ Yes El No
<br />35. WERE AUTOPSY FINDINGS AVAILABLE TO
<br />COMPLETE THE CAUSE OF DEATH?
<br />❑ Yes ❑ No
<br />36. MANNER OF DEATH 37. DID TOBACCO USE CONTRIBUTE 38. IF FEMALE: 39. IF TRANSPORTATION INJURY,
<br />® Natural TO DEATH? SPECIFY:
<br />® Not pregnant within past year ❑ Driver /Operator
<br />❑ Accident ❑ yes [3 Pregnant at time of death ❑ Passenger
<br />❑ Suicide 10 No ❑ Net pregnant, but pregnant within 42 days 01 death ❑ Pedestrian
<br />El ❑ Probably El Not pregnant, but pregnant 43 days to one year before death ❑ Other (Specify)
<br />El Investigation El Unknown ❑ . Unknown it pregnant within the past year
<br />❑ Could not be determined
<br />400. DATE OF INJURY(mm- dd -ysy) 40b.TIME OF INJURY 40c. INJURY AT WORK? 404. PLACE OF INJURY (e.g, Decedent's home, construction site, restaurant, wooded area)
<br />❑ Yes ❑ No
<br />40e. LOCATION (Street and Number, Ciy,State,Zip Code) 401. COUNTY OF INJURY
<br />41. DESCRIBE HOW INJURY OCCURRED
<br />42e. REGISTRAR FILE NO. 42b. DA RECEIVED BY LOCAL REGISTRAR 42c. REGISTRAR
<br />01014 Al Irl IRT R 2017 REGISTRAR - ELLIS COUNTY CLERK, ELECTRONICALLY FILED
<br />CERTIFICATION
<br />EDR NUMBER 000002146648
<br />DEPARTMENT OF STATE HEALTH SERVICES
<br />VITAL STATISTICS UNIT
<br />This is a true and correct reproduction of the original record as recorded in this office. Issued under
<br />authority of Section 191.051, Health and Safety Code.
<br />WARNING: THIS DOCUMENT HAS A DARK BLUE BORDER AND A COLORED BACKGROUND
<br />1` ytrALTERAT
<br />FIA IEMC* HI* E_RTIFICATE
<br />TARA DAS
<br />STATE REGISTRAR
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