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P <br />STATE OF FLORIDA <br />THIS DOCUMENT HAS A LIGHT BACKGROUND ON TRUE WATERMARKED PAPER. HOLD TO LIGHT TO VERIFY FLORIDA WATERMARK. <br />STATE FILE NUMBER: 2017195771 <br />DECEDENT INFORMATION <br />NAME: GREGG A PETERSON <br />DATE OF DEATH: December 14, 2017 SEX: MALE AGE: 070 YEARS <br />DATE OF BIRTH: October 3, 1947 SSN: 505 -60 -5888 <br />BIRTHPLACE: FREMONT, NEBRASKA, UNITED STATES <br />PLACE WHERE DEATH OCCURRED: WIFE'S HOME <br />FACILITY NAME OR STREET ADDRESS: 6815 S ENGLEWOOD AVENUE <br />LOCATION OF DEATH: TAMPA, HILLSBOROUGH COUNTY, 33611 <br />SURVIVING SPOUSE, DECEDENT'S RESIDENCE AND HISTORY INFORMATION <br />MARITAL STATUS: MARRIED <br />SURVIVING SPOUSE NAME: CYNTHIA LAMBERT <br />RESIDENCE: 2826 LAKEWOOD CIRCLE, GRAND ISLAND, NEBRASKA 68801, UNITED STATES <br />COUNTY: HALL <br />OCCUPATION, INDUSTRY: DOCTOR, MEDICAL <br />RACE: X White _Black or African American _Asian Indian _Chinese _Filipino _Native Hawaiian <br />_American Indian or Alaskan Native -- Tribe: _Japanese _Korean _Vietnamese <br />_Guamanian or Chamorro _Samoan _Other Pacific Is]: <br />Other Asian: _Other: _Unknown <br />HISPANIC OR HAITIAN ORIGIN? NO, NOT OF HISPANIC /HAITIAN ORIGIN <br />EDUCATION: DOCTORATE OR PROFESSIONAL DEGREE EVER IN U.S. ARMED FORCES ?YES <br />PARENTS AND INFORMANT INFORMATION <br />FATHER /PARENT: HAROLD PETERSON <br />MOTHER /PARENT: LOUISE MCKEAN <br />INFORMANT: CYNTHIA PETERSON <br />RELATIONSHIP TO DECEDENT: WIFE <br />INFORMANTS ADDRESS: 2826 LAKEWOOD CIRCLE, GRAND ISLAND, NEBRASKA 68801, UNITED STATES <br />PLACE OF DISPOSITION AND FUNERAL FACILITY INFORMATION <br />PLACE OF DISPOSITION: PALM STATE CREMATORY SERVICES <br />CLEARWATER, FLORIDA , <br />METHOD OF DISPOSITION: CREMATION <br />FUNERAL DIRECTOR /LICENSE NUMBER: THOMAS J. COHEN, F043919 <br />FUNERAL FACILITY: CREMATIONS OF GREATER TAMPA BAY INC F094876 <br />4021 HENDERSON BLVD, TAMPA, FLORIDA 33629 <br />CERTIFIER INFORMATION <br />TYPE OF CERTIFIER: CERTIFYING PHYSICIAN MEDICAL EXAMINER CASE NUMBER: NOT APPLICABLE <br />TIME OF DEATH (24 hr): 1945 DATE CERTIFIED: December 20, 2017 <br />CERTIFIER'S NAME: CHAD A FARMER <br />CERTIFIER'S LICENSE NUMBER: ME90305 <br />NAME OF ATTENDING PHYSICIAN (If other than Certifier): NOT ENTERED <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. THE DOCUMENT WILL NOT PRODUCE <br />A COLOR COPY. <br />1 <br />* 3 6 1 2 0 1 0 1* <br />Il <br />BUREAU of VITAL STATISTICS 201801404 <br />CERTIFICATION OF DEATH <br />, State Registrar <br />DATE ISSUED: December 21, 2017 <br />STATE FILE DATE: December 20, 2017 <br />DH FORM 1946 (03 -13) <br />REQ: 2018803689 <br />CERTIFICATION OF VITAL RECORD <br />w►G <br />Trida <br />HEALTH <br />