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1. Decedent's Legal Name (Firsr, Last) TOMAS YOEL TICUM VENTURA 2. Sex MALE ' Date Of Death (Month, Day, Year) 10/21/2015 4. Social Security Number 507 -51 -6046 5. Date Filed i3yState Registrar 11/16/2015 6. Last Name Prior to First Marriage 7a.Date Of Birth 08/31/1966 7b. Age 49 YEAR(S) 8. Place Of Birth (City And State Or Foreign Country) CHICHICASTENANGO, GUATEMALA 9. Decedent Ever In U.S. Armed Forces NO 10a. Place Of Death INPATIENT 10b. Facility Name (If 'lot Institution, Street And Number) VIA CHRISTI - ST FRANCIS 10c. County Of Death - SEDGWICK 10d. Zip Code 67214 10e. City or Town Of Death WICHITA 11. Marital Status MARRIED 12, Surviving Spouse (Name Prior to First Marriage) ORQJIDIA ARCHILA 13a. Residence- 411 13e. Zip 67209 Street Address S WESTFIELD ST 13b. State or Foreign Country KANSAS 13c. County or Province SEDGWICK 13d. City or Town WICHITA Code 131. Inside City Limits YES GUATEMALAN • _ rtecr.! Par GUATEMAL,N 16. Decedent's Hispanic Origin y CENTRAL AMERICAN 17. Decedent's Education MASTERS DEGREE Occu 18.'Decedents pption OFFICIANT AND PASTOR 1U. Decedent's Industry CLERGY 20. Father /Parent Birth Name (First, Middle, Last) i TOMAS TICUM F',IQUTAC 21. Mother /Parent Birth Name (First, Middle, Last) JUANA VENTURA SEN 22a. Informant's Name (First, Middle, Last) THOMSON TICUM 22b. Mailing Address (Street, Number, City, State, And Zip Code) 411 S WESTFIELD ST, WIC. -IITA, KANSAS 67209 22c. Relationship To Decedent SON 23. Method Of Disposition'' BURIAL 24a. Place Of Disposition GREENWOOD CEMETERY 24b. Location WICHITA, KANSAS 25. Funeral Service Licensee And License Number /s/MAIRA A SALAZAR - 5620 26. Name Of Embalmer And License Number RACHEL HALL - 3818 27. Name And Address Of Firm BROADWAY MORTUARY, 1147 S BROADWAY STREET, WICHITA, KANSAS, 67211 28. Cause Of Death Part I. Events (diseases, injuries, or complications) that directly caused the death. IMMEDIATE CAUSE (Final a. NEUROLOGIC DEATH Approximate Interval: Onset To Death Disease Or Condition Resulting Due To (Or As A Consequence Of): In Death) / b. INTRACRANIAL I-IYPEIRTENSION SECONDARY TO STROKE Conditions, if any, leading Due To (Or As A Consequence Of): To cause listed on line a. C. LEPTOMENINGEAL C-ARCINOMATOSIS UNDERLYING CAUSE (disease Due To (Or As A Consequence Of). or injury that Initiated the d. M. A ATI ,N • ° D 011._11.14 `. UNKNOWN PRIMAR events res;.itlnq in death) LISTED LAST - ^ ,^ Part H. Other Sigrlificant Conditions Contributing To Death But Not Resulting In The Underlying Cause Given In Part I. RESPIRATORY FAILURE; ACUTE ISCHEMIC STROKE 29a. Autopsy YES ' 29b. Autopsy Findings Available To Complete The Cause Of Death UNKNOWN 29c. Coroner Contacted UNKNOWN 30. Did Tobacco Use Contribute To Death? UNKNOWN 31. If Female: 32. Manner Of Death NATURAL 33a. Date Of Injury (Month, Day, Year) 33b. Time Of Injury 33e. I njury At Work 33d. How Injury Occurred 33e. Place Of Injury 33f. Location (Street And Number Or Rural Route, City Or Town, State, And Zip Code) 34a. Date Pronounced Dead (Month, Day, Year) 10/21/2015 34b. Time Pronounced Dead 1005 34c. Actual Or Presumed Time Of Death 1005 34d. Name Of Person Pronouncing Death JUSTIN SANDALL DO 34e. Ucense No. 535487 35a. Pronouncing and Certifying Physician /s /JUSTIN C SANDALL - DO 35b. License No. 535487 35 bate Certified 11/02/2015 35d. Address And Zip Code Of Person Completing Cause Of Death 929 N ST FRANCIS, WICHITA, KANSAS, 67214 Kansas Department of Health and Environment Office of Vital Statistics CERTIFICATE OF DEATH VS231A - Rev. 07/01/2099 Death 11/18/2015 V230174605 11 TICUM VENTURA 201504021627 5e 201707163 115-2015-21627 State File Number