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CERTIFICATION OF VITAL RECORD
<br />REGISTER OF DEEDS - HEALTH DEPARTMENT
<br />CHARLOTTE, NORTH CAROLINA
<br />CERTIFICATE OF DEATH 201904028
<br />TYPE/PRINT IN
<br />PERMANENT
<br />BLACK, BLUE -
<br />SLACK OR
<br />BLUE INK
<br />OHMS talc
<br />EED 11/201E1
<br />NRC VITAL RECORDS
<br />NORTH CAROLINA DEPARTMENT OF HEALTH AND HUMAN SERVICES
<br />N.C. VITAL RECORDS
<br />REGISTRATIO CERTIFICATE OF DEATH
<br />DISTRICT NO. l/'VE 1 5 LOCAL NC %Ir )B M LINTY OF DEATH Mecklenburg
<br />STATE FILE NO
<br />T'S LEGAL NAME
<br />a
<br />r FIRST
<br />ke Jeanette
<br />lb. MIDDLE
<br />Eleanor
<br />1e LAST
<br />ay Neill
<br />1d. SUFFIX
<br />1e LAST NAME PRIOR TO FIRST
<br />MARRIAGE
<br />Currier
<br />2 SEX
<br />F
<br />3a. AGE -LAST
<br />BIRTHDAY(
<br />(Yrs)
<br />103(
<br />3b. Ur,9tP t) 1 YEAR
<br />3c. UNDER 1 DAV
<br />4 DATE OP BIRTH (Month/Day/ear}
<br />6/2/1916
<br />S. BIRTHPLACE
<br />(Courdyditaec Foreign Country)
<br />Gage Co., Nebraska
<br />a DATE OF DEATH (Month/Day/Year)
<br />7/4/2019
<br />Months
<br />Day.
<br />Hous
<br />Minute.
<br />Ps ECD
<br />O Inpabant
<br />T•J(TM(.'1ItI11 4.1VitJIa ii i'ITAL 7b. IF DEATH OCCURRED SOMEWHERE OTHERTHAN A HOSPITAL
<br />O ER/ONpa ent 0 DOA O Hospice Maly 0 Nuab'p home&ong term care reality 0 Decadent. home 0 Other (Speak)
<br />/0. FAC LI t V NAME (If nal institution, give street and number)
<br />Stewart Health Center
<br />7d CI re OR TOWN
<br />Charlotte
<br />7irratorrer rum -
<br />Mecklenburg
<br />8 MARITAL STATUS
<br />0 Manned 0 Married, but separated 0 Widowed
<br />❑ Divorced O Never married 0 Unknown
<br />a. SURVIVING SPOUSE (Give name10a.
<br />poor to first mamas.)
<br />DECEDENT'S USUAL OCCUPATION
<br />(Do not use retired)
<br />Schematic Administrator
<br />1 Ob. KIND OF BUSINESS/INDUSTRY
<br />Aeronautics
<br />11. BODITL SECU-RT'rY IJDMBER-j12aR-ES15E-N-CE-STATE OTFOFE.ION COUE)RY-2b
<br />508-12-9788 I North Carolina
<br />OLIN rY
<br />Mecklenburg
<br />l2c-12E
<br />Charlotte
<br />• 12d. STREE r AND NUMBER
<br />6920 Marching Duck Drive
<br />12e. INSIDE TY LIMITS
<br />t[7 Vu �No
<br />121. ZI CODE
<br />28210
<br />i3. WAS DECEDENT EVER IN
<br />U.S. ARMED FORCES?
<br />D Yes nil No
<br />14. DECEDENT'S EDUCATION (Check the box that
<br />best describes the Nghest degree or level of school
<br />coO Berleted tor team d death)
<br />grade
<br />1S. DECEDENT OF HISPANIC ORIGIN? (Check the
<br />box that beet describes whether the decadent Is
<br />Spanish/Hisdecedent Is non Spanish/Hispanic/Latino) eb Check box I/
<br />18, DECEDEN rRACE (Check one more races to Indicate whet the
<br />decedent considered
<br />idered himself or herself to be)
<br />0 White 0 Other Asian (Speedy)
<br />0 Black or African American
<br />Oath -12th grade, no spiloma
<br />❑High school graduals or OED completed
<br />Doom. college credd, but no degree
<br />o
<br />OAsaoate degree (.5. AA. AS)
<br />O Bachelors deree (e.g.. B.A. AB. BS)
<br />0 No, not Spanish/Hispanic/Latino
<br />O Yes. Mexican, Mexican American Chicano
<br />O Yes, Puerto Rican
<br />I0 Yes. Cuban
<br />DYes, other SpasshMrvcitn
<br />iapaab(Speedy)'
<br />0Afrpncan Indian or Alaska 0 Native Hawaiian
<br />Neve (Name of the enrolled or OGuamanian or Chamorro
<br />ems',
<br />nnrio el 0 Samoan
<br />O Otter Pacific Islander (Speay)
<br />❑Asian Indian ❑ Jona..,
<br />O Masters degreeleg . MA, MS. MEng, MEd. MSW. MBA)
<br />❑ Chinese 0 Korean 0 Oma (Speedy)
<br />0 Doctorate (e.g., PhD. EdD) or Pro/esaonal degree
<br />MD, DVM.
<br />0 Filipino 0 Nelnemese
<br />(e.g., DOS, LLB, JO
<br />'17. FATHER/PARENT NAME (Feet, Middle, Last) (Last Name Prior
<br />Earl Currler
<br />to Firet Marriage) 18. MDTF(ER/PARENT NAME (First. Middle. Lard) (Last Name Prior to First Marrero.)
<br />Inez Falwel
<br />19. INFORMANT'S NAME lab. RELATIONSHIP TO DECEDENT c. MAILING ADDRESS (Street and Number. City, State, Zip Code)
<br />KIrstina Nickels Daughter -In -Law 5713 Randolph Road, Charlotte, NC 28270
<br />I20a METHOD OF DISPOSITION 0 Bunts Cremation
<br />O Donation D Entombment O Removal'rom State
<br />0 Other (Speedy)
<br />20b PLACE OF DISPOSITION ( ame of cemetery. crematory,
<br />other place)
<br />Forest Lawn West Crematory
<br />20c. LOCATION (City or Town and State)
<br />Charlotte, NC
<br />21 a. SIGNATURE OF FUNERAL DIRECTOR
<br />as +
<br />^Ib. LICENSE NUMBER
<br />F51819
<br />21c. NAME OF EMBALMER
<br />John Marlow
<br />21d LICENSE NUMBER
<br />FS2210
<br />22..e
<br />ME AND ADDRESS OF F Jl NERAL HOME
<br />McEwen Funeral Home - Pineville Chapel, 10500 Park Road, Charlotte, NC 28210
<br />123. PariTFnler a-rbalRofewan asusea, in -(3 Junes or�Icabons) that directly caused the death. DO NOT enter terminal events s4& as cardIec arrest,
<br />respiratory an eel. or venin..ler ebnlleuon wid•oul showing the etiology on lines b. c endor d Enter Only one cause on a line. DO NOT ABBREVIATE
<br />IMMEDIATE l disease
<br />CAUSE . e -r k Ci�E � 2y S '«Ar'
<br />(Final dleeeseumnabonV\ ',A��.n_-�- /VIrL J1 es1'_t .L
<br />Approxarete Interval
<br />Onset to death
<br />uWrn m death)Sno (a ea . conaeouenca o�
<br />ba ate Muer B.
<br />deg3, Redinyg
<br />Mad. tharIn.
<br />UMadND on Me a: Enter the pica. to (c ea a consequence of)
<br />kn.g.
<br />UNDERLYING CAUSE
<br />try seen ry that c'
<br />e ou events resulting Ws b (a u a consequence of)
<br />'baled the
<br />In death) LAST d
<br />PANT U. Omerggattjos,t rood n p but not resulting in the underlying
<br />"u�'p�I� In PART
<br />iU er) Cu-1rr,.-i L ✓rR-inu ' fi•orL, CErebrovic6scvaa ,(111:
<br />C- 2 .'c-lc;o(Ale ea kt ,-KnsiOn
<br />24a. WAS ANA PSV PERFORMED?
<br />e_OV$a No
<br />ttJ`C
<br />24b. WERE AUTOPSY
<br />T❑O COMPLETEET
<br />FINDINGS AVAILABLE
<br />THE CAUSE OF DEATH?
<br />26. MANrN5f�'1rn� OF DEATH •
<br />MaidEurai 0 Homicide
<br />DAccltlenl O Pending
<br />-da WAS CASE REFE RED TO
<br />MEDICAL EXAMINER?
<br />Oyes lat✓
<br />27. TIME OF DEATH
<br />(Approximate)
<br />28 DID TOBACCO USE
<br />CONTRIBUTE TO DEATH?
<br />DYes 0 Probably
<br />29. IF FEMALE
<br />0 Pregnant at time of death
<br />past near
<br />pregnant whir
<br />O Stuade 0 Cannot be
<br />determined
<br />26b. IF YES
<br />0 Declined by Medicalpregnant,
<br />Examiner
<br />taw- 0 unknwn
<br />pregnantn
<br />but within 42 days d death
<br />0 Not pregnant, p but pregnant In daysst y 1 year before death
<br />0 Unknown if regnant within In peal%e
<br />30. DATE PRONOUNCED
<br />(Montrvoay Yvan
<br />31a. DATE OF INJURY
<br />(MoneVDay/Yea)
<br />31b. TIME OF
<br />INJURY
<br />Glc. INJURY AT VWORK?
<br />0 yes 0 No
<br />31d. PLACE OF INJURY -at horn.. farm, street,
<br />factory. oMce, building, etc
<br />I31e. IF TRANSPORTATION INJURY
<br />I SPECIFY
<br />0 Dnvar/Opercor
<br />0 Passenger
<br />91f DESCRIBE HOW INJURY OCCURRED 1310 LOCATION
<br />OF INJURY (Street/Number/Gay/Stale)
<br />0 Pedestrian
<br />0 Other (Specify)
<br />32. geRTIFIER (Check only one)
<br />enirying physician/nurse oracbbonertphysioen asodted - To the beet of my knowledge, death occurred at the time. date, end place end
<br />Medical Examiner - On the basis d examination, and/or inv.,• bon, in m o• mon death occurred al the time, date, end , end due
<br />due to lie cause(*) and manner stated
<br />to the causes and manner staled
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<br />REM(S) CORRECTED
<br />DA. FAA/ b./DEO (MoIDayrYr'/
<br />ITEM(S)AMENDED
<br />THIS IS TO CERTIFY THIS IS A TRUE AND CORRECT REPRODUCTION OF THE
<br />OFFICIAL RECORD FILED IN MECKLENBURG COUNTY.
<br />V 1230795
<br />WITNESS MY HAND AND OFFICIAL SEAL THIS DAY July 9, 2019
<br />eug0 Gibbie Harris Fredrick Smith
<br />rl c0 Health Director & Registrar Register of Deeds
<br />g� Z
<br />►� < By:
<br />x x z
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