|
11111,,[11'111,1- -!II Illdllf II IP p 4111
<br />CERTIFICATION OF VITAL RECORD,
<br />DEPARTMENT OF STATE HEALTH SERVICES
<br />VITAL STATISTICS
<br />TEXAS DEPARTMENT OF STATE HEALTH SEFkVICES - VITAL STATISTICS
<br />Mar 31 2020
<br />STATE OF TEXAS CERTIFICATE OF DEATH
<br />STATE FILE NUMBER
<br />2 °1 Val 3 0
<br />1. LEGAL NAME OF DECEASED (Include AKA's, if any) (First, Middle, Last) r (Before Marriage)
<br />GARY LEE HEDMAN
<br />2. DATE OF DEATH - ACTUAL OR PRESUMED
<br />(mm-dd-yyW)
<br />MARCH 26, 2020
<br />3. SEX
<br />MALE
<br />4. DATE OF BIRTH (min-dd-yyyy)
<br />JUNE 8, 1943
<br />5. AGE -Last Birthday
<br />(Yrs) 76
<br />IF UNDER
<br />1 YR
<br />IF UNDER
<br />1 DAY
<br />6 BIRTHPLACE (City & State or Foreign Country)
<br />MANHATTAN, KS
<br />Me
<br />Days
<br />t.,re
<br />Mn
<br />7. SOCIAL SECURITY NUMBER
<br />512-40-5677
<br />8. MARITAL STATUS AT TIME OF DEATH-
<br />® Married WKlowed (bet not mamied)
<br />❑ Divorced (but not remarried) g ro
<br />Never Marred ❑unknown
<br />9. SURVIVING SPOUSES NAME (If spouse. give name prior to first marriage)
<br />DEANNA CASEBEER
<br />10a. RESIDENCE STREET ADDRESS
<br />349 SUNSET DR
<br />10b. APT. NO.
<br />10c. CITY OR TOWN
<br />DONIPHAN
<br />(0d. COUNTY
<br />HALL
<br />10e. STATE
<br />NEBRASKA
<br />101. ZIP CODE
<br />68832
<br />10g. INSIDE CITY LIMITS?
<br />❑ Yee ®No
<br />11. FATHER/PARENT 2 NAME PRIOR TO FIRST MARRIAGE
<br />LAWRENCE HEDMAN
<br />12. MOTHER/PARENT 1 NAME PRIOR TO FIRST MARRIAGE
<br />LOIS MEYER
<br />13. PLACE -OF DEATH (CHECK ONLY ONE)
<br />IF DEATH OCCURRED IN A HOSPITAL:
<br />0Inpatient ❑ ER/Outpatient 0 DOA
<br />IF DEATH OCCURRED SOMEWHERE OTHER THAN A HOSPITAL:
<br />0 Hospice Facility 0 Nursing Home 0 Decedents Home ❑ Other (Specify)
<br />14. COUNTY OF DEATH
<br />WICHITA
<br />15. CITY/TOWN, ZIP (IF OUTSIDE CITY LIMITS. GIVE PRECINCT NO)
<br />WICHITA FALLS, 76301
<br />18. FACILITY NAME (K not Instn/inn., give street address)
<br />UNITED REGIONAL HEALTH CARE
<br />17. INFORMANTS NAME & RELATIONSHIP TO DECEASED
<br />DEANNA HEDMAN -SPOUSE
<br />18. MAILING ADDRESS OF INFORMANT (Street and Numbor,City,Stete,Zip Code)
<br />349 SUNSET DR, DONIPHAN, NE 68832
<br />19. METHOD OF DISPOSITION
<br />❑ Burial 0 Cremation 0 Donation
<br />❑ Entombment ® Removal from state 0 ,„,„,„01„,,,,,i.,.Section
<br />❑ other (saedty1DAVID
<br />20. SIGNATURE
<br />AS SUCH
<br />AND LICENSE NUMBER OF FUNERAL DIRECTOR OR PERSON ACTING
<br />NEWTON,BY ELECTRONIC SIGNATURE - 09679
<br />21. ®Unknown
<br />Block
<br />Lot
<br />22. PLACE OF DISPOSITION (lama of cemetery, crematory, other place)
<br />CEDARVIEW CEMETERY
<br />23. LOCATION (City/Town, and State)
<br />DONIPHAN, NE
<br />Spm
<br />24. NAME OF FUNERAL FACILITY
<br />WICHITA FALLS EMBALMING SERVICE
<br />25. COMPLETE. ADDRESS'. OF FUNERAL FACILITY (Street end Number, City, State, Zip Code)
<br />3009 GRANT STREET, WICHITA FALLS, TX 76308
<br />28. CERTIFIER (Check only one)
<br />® Certifying physician -To are best of my knowledge, death occurred due to the ...Oland manner stated.
<br />❑ Medical ExeminerlJuetice of the Peace - On the basis of examination; and/or InvBollgellon. In myc7nlon, death occurred at the time,dete and place, and due to the cause(s) and manner slated.
<br />27.SIGNATURE OF CERTIFIER
<br />SRINIVASA R MANDADAPU , BY ELECTRONIC SIGNATURE
<br />28. DATE CERTIFIED (mm-0tl-WW)
<br />MARCH 30, 2020
<br />29. LICENSE NUMBER
<br />L8121
<br />30. TIME OF DEATH(Aotual or presumed)
<br />06:44 PM
<br />31. PRINTED NAME, ADDRESS OF CERTIFIER (Street and Number. CIty,State,Zip Code)
<br />SRINIVASA R MANDADAPU 1600 11TH ST., WICHITA FALLS, TX76301
<br />32. TITLE OF CERTIFIER
<br />MD
<br />CAUSE OF DEATH i
<br />33. PART 1. ENTER THE CHAIN OF EVENTS - DISEASES. INJURIES, OR COMPLICATIONS - THAT DIRECTLY CAUSED THE DEATH. DO NOT ENTER
<br />Approximate interval
<br />Onset to deem
<br />3 DAYS
<br />TERMINAL EVENTS SUCH AS CARDIAC ARREST, RESPIRATORY ARREST. OR VENTRICULAR FIBRILLATION WITHOUT SHOWING THE
<br />ETIOLOGY. DO NOT ABBREVIATE. ENTER ONLY ONE CAUSE ON EACH.
<br />IMMEDIATE CAUSE (Final
<br />diea.e or condition--> a, SEPTIC SHOCK
<br />resulting In death)
<br />3 DAYS
<br />/ Due.t0 (oras a consequence of):
<br />5e°uermagyllatconditions
<br />If any, leading to the cause ' b. ACUTE HYPDXIC RESPIRATORY:FAILURE
<br />3 DAYS
<br />listed on linea. Enter ma Due to (or as a con008000108 °R'
<br />UNDERLYING CAUSE
<br />(disease or injury that
<br />10180ted, the events resulting c. PNEUMONIA •
<br />in death) LAST
<br />5DAYS
<br />Due. to (or as a consequence of):
<br />d. INFLUENZA
<br />PART 2. ENTER OTHER SIGNIFICANT CONDITIONS CONTRIBUTING TO DEATH BUT NOT RESULTING IN THE UNDERLYING
<br />34. WAS AN AUTOPSY PERFORMED?
<br />0 Yes ® No
<br />CAUSE GIVEN IN PART I.
<br />35. WERE AUTOPSY FINDINGS AVAILABLE TO COMPLETE
<br />THE CAUSE OF DEATH?
<br />El ''''.5 ❑Ne
<br />36. MANNER OF DEATH
<br />® Nalurel
<br />0 Accident
<br />❑ Suicide
<br />❑ Homicide I
<br />\
<br />❑ Pending Inves5ga0on
<br />❑ Could not be determined
<br />37. DID TOBACCO USE CONTRIBUTE
<br />TO DEATH?
<br />0 Yes
<br />® No
<br />❑ Previously
<br />0 Probably
<br />❑ Unknown
<br />38.
<br />0
<br />❑
<br />0
<br />❑
<br />0
<br />IF FEMALE:
<br />Not pregnant within pest year
<br />Pregnant at time of death
<br />Not pregnant, but pregnant within 42 days of death
<br />Notpregnant, but pregnant 43 days to one year before death
<br />Unknown 7 pregnant within the bast year
<br />39. IF TRANSPORTATION INJURY. SPECIFY:
<br />0 Driver/Operator
<br />❑ Passenger
<br />❑ Pedestrian
<br />❑time (Specify)
<br />40e. DATE OF INJURY(mm+)d-yyyy)
<br />406 TIME OF INJURY
<br />40c. INJURY AT WORK?
<br />❑Yes ❑Ne
<br />40d. PLACE OF INJURY (0.0, Decedent's fame, construction she, restaurant. wooded area)
<br />40e. LOCATION (Street and Number, City,Stote,Zrp Code)
<br />40f. COUNTY OF INJURY
<br />41. DESCRIBE HOW INJURY OCCURRED
<br />42. REGISTRAR FILE NO.
<br />02000367
<br />42b. DATE RECEIVED BY LOCAL REGISTRAR
<br />MARCH 31, 2020
<br />42c. REGISTRAR q)
<br />EDR NUMBER 000044444692765
<br />This is a true and correct copy of the record as registered in the State of Texas. Issued under the
<br />authority of Section 191.051, Health and Safety Code.
<br />ISSUED Apr01 2020
<br />TARA DAS
<br />STATE REGISTRAR
<br />1Y% WARNING:THIS DOCUMENT HAS A DARK BLUE BORDER AND A COLORED BACKGROUND
<br />ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE
<br />
|