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MISSOURI <br />THE REPRODUCTION OF THIS DOCUMENT IS PROHIBITED BY LAW. <br />ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATION. <br />(.1 <br />DATE OF <br />BIRTH: <br />CERTIFICATION OF DEATH 6 4 0 18 0 3 8 9 3 <br />DATE FILED: APRIL 5 , 2 018 STATE FILE NUMBER: 124 <br />DECEDENT NAME: THOMAS J MOORE JR SEX: MALE <br />DATE OF COUNTY <br />DEATH: MARCH 29, 2 018 OF DEATH: CLAY <br />SOCIAL <br />SECURITY NUMBER: <br />JANUARY 28, 1936 <br />513 -30 -8180 <br />DATE ISSUED: MAY 8, 2018 <br />MARITAL <br />STATUS: <br />RESIDENCE <br />ADDRESS: <br />DIVORCED <br />SURVIVING SPOUSE: <br />OF WIFE, MAIDEN NAME): <br />FUNERAL HOME: PENWELL -GABEL MID -TOWN CHAPEL <br />UNDERLYING CAUSE (ICD CODE): (C920) MANNER: NATURAL <br />ACUTE MYELOBLASTIC LEUKEMIA - UNKNOWN <br />EVER IN <br />ARMED FORCES: YES <br />1201 NW TULLISON ROAD <br />KANSAS CITY,MISSOURI <br />ISSUED ON BEHALF OF MO DEPT HEALTH & SENIOR SERVICES:HENRY <br />THIS IS A TRUE CERTIFICATION OF NAME AND DEATH FACTS AS RECORDED BY THE BUREAU OF VITAL RECORDS, JEFFERSON CITY, MISSOURI. ` N ,\ �� ",111llilllll „# �� , <br />����� HEALT84. <br />/../ .-.:-.” ,ar. <br />Craig B. Ward F. i <br />State Registrar of Vital Statistics <br />