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201706769
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12/9/2019 6:29:07 PM
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10/5/2017 12:29:23 PM
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201706769
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STATE OF FLORIDA <br />MONO <br />CERTIFICATION OF VITAL RECORD <br />I <br />;' <br />b <br />c <br />d <br />1 <br />THIS DOCUMENT HAS A LIGHT BACKGROUND ON TRUE WATERMARKED PAPER. HOLD TO LIGHT TO VERIFY FLORIDA WATERMARK. <br />STATE FILE NUMBER: 2017072060 <br />DECEDENT INFORMATION <br />NAME: JOEL C HOFFMAN <br />DATE OF DEATH: May 6,2017 SEX: MALE SSN: 462 -78 -2596 AGE: 067 YEARS <br />DATE OF BIRTH: February 19, 1950 BIRTHPLACE: OMAHA, NEBRASKA, UNITED STATES <br />PLACE OF DEATH: HOSPICE <br />FACILITY NAME OR STREET ADDRESS: GOOD SHEPHERD HOSPICE <br />LOCATION OF DEATH: AUBURNDALE, POLK COUNTY, 33823 <br />SURVIVING SPOUSE, DECEDENT'S RESIDENCE AND HISTORY INFORMATION <br />MARITAL STATUS: MARRIED <br />SURVIVING SPOUSE NAME: CINDE TYMA <br />RESIDENCE: 9705 LAKE BESS ROAD LOT 543, WINTER HAVEN, FLORIDA 33884, UNITED STATES COUNTY: POLK <br />OCCUPATION, INDUSTRY: WELDER, FARM EQUIPMENT <br />RACE: X White _Black or African American _Asian Indian _Chinese Filipino _Native Hawaiian _Japanese _Korean <br />_American Indian or Alaskan Native -- Tribe: Vietnamese _Other Asian: <br />_Guamanian or Chamorro Samoan _Other Pacific Isl: _Other: _Unknown <br />HISPANIC OR HAITIAN ORIGIN? NO, NOT OF HISPANIC /HAITIAN ORIGIN <br />EDUCATION: HIGH SCHOOL GRADUATE OR GED COMPLETED EVER IN U.S. ARMED FORCES? YES <br />PARENTS AND INFORMANT INFORMATION <br />FATHER/PARENT: CHARLES HOFFMAN <br />MOTHER/PARENT: LUCILLE JORGENSEN <br />INFORMANT: CINDE HOFFMAN <br />RELATIONSHIP TO DECEDENT: WIFE <br />INFORMANTS ADDRESS: 9705 LAKE BESS ROAD LOT 543, WINTER HAVEN, FLORIDA 33884, UNITED STATES <br />PLACE OF DISPOSITION AND FUNERAL FACILITY INFORMATION <br />PLACE OF DISPOSITION: STEELE'S FAMILY FUNERAL SERVICES <br />WINTER HAVEN, FLORIDA <br />METHOD OF DISPOSITION: CREMATION <br />FUNERAL DIRECTOR/LICENSE NUMBER: SUSAN P. STEELE, F031998 <br />FUNERAL FACILITY: STEELES FAMILY FUNERAL SERVICES F041348 <br />207? BURNS LANE, WINTER HAVEN, FLORIDA 33884 <br />CERTIFIER INFORMATION <br />TYPE OF CERTIFIER: CERTIFYING PHYSICIAN MEDICAL EXAMINER CASE NUMBER: NOT APPLICABLE <br />TIME OF DEATH (24 hr): 0755 DATE CERTIFIED: May 8, 2017 <br />CERTIFIERS NAME: SARA A BOHN <br />CERTIFIER'S LICENSE NUMBER: 0S13725 <br />NAME OF ATTENDING PHYSICIAN (If other than Certifier): NOT APPLICABLE <br />CAUSE OF DEATH AND INJURY INFORMATION <br />MANNER OF DEATH: NATURAL <br />CAUSE OF DEATH - PART I - and Approximate Interval: Onset to Death: <br />a PLASMA CELL LEUKEMIA <br />PART II - Other significant conditions contributing to death but not resulting in the underlying cause given in PART I: <br />RENAL INSUFFIENCY, HYPERTENSION, CARDIOMYOPATHY, CORONARY ARTERY DISEASE, CHRONIC OBSTRUCTIVE <br />PULMONARY DISEASE <br />AUTOPSY PERFORMED? NO AUTOPSY FINDINGS AVAILABLE TO COMPLETE CAUSE OF DEATH? <br />DATE OF SURGERY: DID TOBACCO USE CONTRIBUTE TO DEATH? NOT STATED <br />REASON FOR SURGERY: <br />IF FEMALE, NOT APPLICABLE <br />DATE OF INJURY: NOT APPLICABLE TIME OF INJURY (24 hr): INJURY AT WORK? <br />LOCATION OF INJURY: <br />DESCRIBE HOW INJURY OCCURRED: <br />PLACE OF INJURY: <br />IF TRANSPORTATION INJURY, Status of Decedent: Type of Vehicle: <br />THE ABOVE SIGNATURE CERTIFIES THAT THIS IS A TRUE AND CORRECT COPY OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE. <br />THIS DOCUMENT IS PRINTED OR PHOTOCOPIED ON SECURITY PAPER WITH WATERMARKS OF THE GREAT <br />WARNING: SEAL OF THE STATE OF FLORIDA, DO NOT ACCEPT WITHOUT VERIFYING THE PRESENCE OF THE WATER - <br />MARKS. THE DOCUMENT FACE CONTAINS A MULTICOLORED BACKGROUND, GOLD EMBOSSED SEAL, AND <br />THERMOCHROMIC FL. THE BACK CONTAINS SPECIAL LINES WITH TEXT. THIS DOCUMENT WILL NOT PRODUCE <br />A COLOR COPY. <br />I 1, 1, 1 1 1 l I I I 1 1 1 1 <br />BUREAU of VITAL STATISTICS 201706769 <br />CERTIFICATION OF DEATH <br />,State Registrar <br />DH FORM 1947 (03-13) <br />DATE ISSUED: May 9, 2017 <br />STATE FILE DATE: May 8, 2017 <br />MONTHS <br />REQ: 2018124818 <br />Florida <br />HEALTH <br />
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