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REGISTRATION AREA NUMBER ,+
<br />/
<br />I. FULL NAME
<br />CERTIFICATE NUMB
<br />,r
<br />��37
<br />STATE PILE NUMBER
<br />OF DECEDENT (fop) (middI) (.) (suffix)
<br />JANEEN VOKOUN
<br />2. SEX •
<br />3. DATE OF DEATH
<br />4. DATE OF BIRTH
<br />S. AGE
<br />IF UNDER I YEAR IF UNDER
<br />MALE FEMALE NOT DETERMINED
<br />❑ 0 ❑
<br />6. WAS DECEDENT EVER
<br />OCTOBER 19, 2016
<br />❑ ACTUAL ❑PRSUMED
<br />❑ APPROXIMATE ❑ FOUND
<br />APRIL 6, 1933
<br />Venn
<br />83
<br />Months
<br />Dm.
<br />Hon
<br />I DAY
<br />'am,
<br />IN U.S. ARMED FORCES?
<br />NO KNO
<br />❑ p UN
<br />7, BIRTHPLACE (U.S STATE OR POREION COUNTRY}
<br />KANSAS
<br />8. SOCIAL SECURITY NUMBER
<br />507 - 34 - 5680
<br />IF NOSSN, CHECK AP
<br />NONE NOT OBTAINABLE
<br />El
<br />ROPRIATE BOX
<br />UNKNOWN
<br />❑
<br />9. STREET ADDRESS (INCLUDE HOUSE AND/OR APT. BOB ROUTE NO.)
<br />303 WEST 28TH STREET
<br />11. COUNTY OF DECEDENTS
<br />10. CITY OR TOWN OF RESIDENCE INSIDE CITY OR TOWN LIMNS?
<br />KEARNEY Dyes 0 m
<br />RESIDENCE (if independent city, lave bleak)
<br />BUFFALO
<br />-.
<br />12. U.S. STATE (OR FOREIGN COUNTRY)OF DECEDENT'S RESIDENCE
<br />NEBRASKA
<br />IL. ZIP CODE
<br />68845
<br />IS RACE OF DECEDENT (CHECK ONE OR MORE)
<br />❑ AMERICAN INDIAN OR ALASKAN NATIVEISPECIFY)
<br />Ow.. ❑ BLACK OR AFRICAN AMERICAN 0 FILIPINO ❑ KOREAN ❑ OTIIER PACIFICISLANDERISPECIFY)
<br />❑ASIAN INDIAN 0 CHINESE ❑ SAMOAN 0 VIETNAMESE ❑ OTHER ASIAN (SPECIFY)
<br />NAIVE HAWAIIAN
<br />❑ ❑ OUAMANIAN OR CHAMORRO 0 JAPANESE 0 UNKNOWN ❑ OTHER(SPECIFY)
<br />14. DECEDENT OF HISPANIC ORIGIN/
<br />ID NON - HISPANIC ❑ CENTRAL OR SOUTH AMERICAN ❑ CUBAN ❑ MEXICAN ❑ PUERTO RICAN ❑ OTHER (SPECIFY) ❑ UNKNOWN
<br />15. EDUCATION (HIGHEST GRADE COMPLETED) ❑ ELEMENTARY/SECONDARY (0.12) ❑ HIGH SCHOOL DIPLOMA ❑OED El YEARS OF COLLEGE I
<br />❑ ASSOCIATE DEGREE ❑ BACHELOR'S DEGREE ❑ MASTER'S DEGREE ❑ DOCTORATE/PROFESSIONAL DEGREE ❑ UNKNOWN
<br />16. CITIZEN OF WHAT
<br />COUNTRY
<br />UNITED STATES OF AMERICA
<br />(9. MARITAL STATUS
<br />17. USUAL OR LAST OCCUPAT ON
<br />COMPUTER OPERATOR
<br />18. KIND OF BUSINESS OR INDUSTRY
<br />GOVERNMENT
<br />❑NEVER MARRIED 0 MARRIED 0 WIDOWED O DIVORCED 0 SEPARATED 0 UNKNOWN
<br />21. NAME
<br />M. IF MARRIED. SEPARATED OR WIDOWED, NAME OF SPOUSE (if divorced lave blank)
<br />OF DECEDENT'S FATHER (FIRST, MIDDLE. LAST, SUFFIX)
<br />LLOYD DONALY
<br />22. MOTHER'S FULL MAIDEN NAME (FIRST, MIDDLE, LAST)
<br />NELLIE BERTRAND
<br />23. INFORMANTS RELATIONSHIP OR SOURCE OF INFORMATION
<br />DAUGHTER
<br />24. FULL NAME OF INFORMANT OR NAME OF SOURCE
<br />PATRICIA VOKOUN
<br />25. NAME OF HOSPITAL OR INSTITUTION OF DEATH (if none, so wle)
<br />INOVA FAIRFAX HOSPITAL
<br />26. SPECIFY IF DEATH
<br />23s. SELECT ONE IF DEATH OCCURRED IN HOSPITAL
<br />DOA OUT PAT Man RM INPATIENT
<br />❑ ❑ O
<br />OCCURRED SOMEWHERE OTHER THAN A HOSPITAL
<br />❑ HOSPICE FACILITY ❑NURSING HOME ❑ LONG TERM CARE FACILITY ❑ DECEDENT'S HOME ❑ CORRECTIONAL FACILITY ❑ OTHER (SPECIFY)
<br />27. CITY OR TOWN
<br />OF DEATH
<br />FALLS CHURCH
<br />28. STREET ADDRESS OR RT. NO OF PLACE OF DEATH
<br />3300 GALLOWS ROAD
<br />25.. ZIP CODE
<br />22042
<br />25b. COUNTY OF DEATH (if independent city, lave blank)
<br />FAIRFAX COUNTY
<br />29. METHOD OF DISPOSmON ._
<br />❑BURIAL ❑ ENTOMBMENT /MAUSOLEUM a CREMATION /INCINERATION ❑ BURIAL AT SEA 0 DONATION ❑ OTHER (SPECIFY)
<br />❑ REMOVAL FROM STATE OF KNOWN, PLEASE ALSO CHECK FINAL METHOD OF DISPOSITION WHEN REMOVING FROM STATE, FROM OPTIONS SHOWN)
<br />30. PLACE
<br />OF DISPOSITION -NAME OF CEMETERY OR CREMATORY
<br />MONEY & KING CREMATION SERVICES
<br />31. PLACE OF DISPOSITION.
<br />STREET ADDRESS OF CEMETERY OR CREMATORY
<br />14522L LEE ROAD
<br />32. SIGNATURE OF FUNERAL
<br />3IR CITY /COUNTY
<br />CHANTILLY
<br />31b. STATE
<br />VIRGINIA
<br />J IB. ZIP CODE
<br />20151
<br />31d. COUNTRY
<br />DIRECTOR/LICENSEE. VSAP OR NEXT OF KIN (ACTUAL SIGNATURE) -
<br />/S/ GARY R. DOWNER
<br />33. NAME
<br />32d. LICENSEE'S NO:.
<br />0502900042
<br />326. NAME OF FUNERAL HOME
<br />MONEY & KING
<br />OR FACILITY
<br />VIENNA FUNERAL HOME
<br />OF FUNERAL DIRECTOR/ LICENSEE, VSAP OR NEXT OF KIN
<br />GARY R. DOWNER
<br />334 STREET ADDRESS OF FUN RAT. HOME/ FACILITY. VSAP OR NEXT OF KIN (Wade want addl., miry, at. ant alp code)
<br />171 W MAPLE AVENUE VIENNA VIRGINIA 22180
<br />34. TIME OF DEATH: To the hat of my knowledge, dash mooned nl 06:54 ❑ A.M. O P.M.
<br />0 ACTUAL ❑ APPROXIMATE ❑. PRESUMED. ❑ FOUND
<br />33. PART I. Enter the disasec, injuries, or complications lhSI caused the death. Do RD enter the made of dying, such as mew or m,pitmory nest, Neck, or been Dilun.
<br />CADS wl11n8 in death) (A) ,VId ^�,� /
<br />at disease AT a re
<br />(Fi(MMEDIATECAUSEOFDBATH / '� ( "•
<br />INTERVAL BETWEEN
<br />ONSET AN
<br />I
<br />Sequentially list conditions. if any, leading OR AS A COHSE E F)
<br />to 'mined.. cause. Enter UNDERLYING ( � /7
<br />insulting death) that Initiated events (B) i , f v '_ I II-. a n`
<br />msullin8 fn dephl LAST tiFA A/C. -�- A1/ '
<br />3 wan /,c
<br />C�. /)
<br />(OR AS A COHSE a DICE fj /� /� L�I,�'l \/y/���'( //
<br />(C)
<br />� T� Vlil / V C 1l ock,
<br />i{Y�("1
<br />'�s7� /,Q,QQ�C
<br />caw ks
<br />IJ TDiO RASAC N$E O
<br />m
<br />PART II. Other significant conditions contributing to but not TvtB in @euMerlyi me Siva In Mn L
<br />36. WAS THE MED ❑ ICALL EXAMINER CONJ:ACIED?
<br />SW-NO
<br />368. AUTOPSY?
<br />❑ � o
<br />36b. WERE FINDINGS AVAILA @ TO COMPLETE CAUSE OF DEATH?
<br />ES p2 -OT'
<br />37. DID TOBACCO US N E CONTRIB TE TO DE TH j?'�UNKNOWN
<br />38.1F FEMALE: SSSeee111
<br />o PREGNANT ST11ME OF DEATH 0 UNKNOWN IF PREGNANT WITHIN THE PAST YEAR ❑N
<br />❑ NOT PREGNANT WITHIN PAST YEAR ❑NOT PREGNANT, BUT PREGNANT WITHIN 43 DAYS T01 YEAR RETORT DEATH T PRE. GNANi .BUT PREGNANT WITHIN 42 DAYS OPDEATH
<br />OT APPLICABLE( if decedent's age B 0.5 or 73 yon)
<br />39.IF EXTERNAL, TO WHAT EXTENT IT CONTRIBUTED TO CAUSE OF DEATH?
<br />❑ PRIMARY ❑ CONTRIBUTING
<br />40. WAS THIS A MILITARY DEATH?
<br />❑ YES ❑ NO
<br />40a. IF MILITARY DEATH, SELECT MANNER OF DEATH
<br />NATURAL ACCIDENT SUICIDE HOMICIDE UNDETERMINED PENDING
<br />❑ ❑ ❑ ❑ ❑ ❑
<br />ITEMS II T047 IN THIS SECTION SHOULD ONLY BE COMPLETED FOR MILITARY DEATHS
<br />41. DATE OF INJURY
<br />41, TIME OF INJURY
<br />❑ A.M. ❑ P.M
<br />43. INJURY AT WORK'/
<br />❑ YES ❑ NO ❑ UNKNOWN
<br />44. PLACE OF INJURY (home.Sm. factory, sired, office. bids, etc.)
<br />43. LOCATION OF INJURY-STREET ADDRESS OEnuna House AMOR Art.apa mourn
<br />4A. CITY /COUNTY
<br />45b. STATE
<br />45c. ZIP CODE
<br />45d. COUNTRY
<br />46.1F TRANSPORTATION INJURY. SPECIFY ❑ DRIVER/OPERATOR ❑ PASSENGER ❑ PEDESTRIAN ❑ OTHER (SPECIFY)
<br />47. DESCRIBE HOW INJURY RELATING TO DEATH OCCURRED
<br />18. SIGNATURE OF PERSO e - 1 .1197 s
<br />- /
<br />48e. TITLE 4IMFDICAL DOCTOR PHYSICIAN ASSISTANT
<br />B ❑ ❑DOCTOR OF OSTEOPATHY (D.O.).
<br />NURSE PRACTITIONER El OTHER
<br />4 8b. DATE ONE,:
<br />yyg111
<br />/0 //)5 /J(
<br />49. NAME OF PERSON
<br />_ ...4I
<br />PROV),. THE MEDICAL
<br />ED
<br />1 r� 11.(
<br />ERTIFI EATH
<br />. fats
<br />w
<br />49,. ADDRESS OF PERSON PROVIDING THE MEDI AL CERTIFICATION OF DEATH
<br />330D bcc s Rd QsChwtli, VA- nab
<br />49b. ME CAL LI ENSE NO.
<br />0101.05-1136-o
<br />50. ARE Y s e A , R'
<br />El YES
<br />E PROVI a HE NAME OF AUTHORIZING OR ABSENT PHYSICIAN
<br />i
<br />518. ADDRESS AUTHORIZING PHYSICIAN
<br />52. SIGN EOP REQISTRAR 52a. PRINTED NAME OF REGISTRAR 52b. DATE RECORD FILED
<br />51 RESERVED FOR REGISTRAR'S USE
<br />HOLD TO LIGHT TO VIEW
<br />0958439 COMMONWEALTH OF VIRGINIA
<br />DEPARTMENT OF HEALTH - DIVISION OF VITAL RECORDS
<br />COMMONWEALTH OF VIRGINIA - CERTIFICATE OF DEATH
<br />DEPARTMENT OF HEALTH - DIVISION OF VITAL RECORDS - RICHMOND
<br />201802453
<br />This is to certify that this is a true and correct reproduction or abstract of the official redord filed with the Virginia Department
<br />Of Health, Richmond, Virginia
<br />DATE ISSUED OCT 2 5 2016
<br />V Janet M. Rainey, State Registrar
<br />Do not accept unless on security paper with the seal of Virginia Department of Health, Vital Statistics in the lower left hand corner.
<br />Section 32.1 -272, Code of Virginia, as amended. VS 15C
<br />2 X
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