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STATE. 0I; ARI74)NA <br />y CERTIFICATION OF VITAL RECORD , <br />ORIGINAL <br />STATE COPY <br />State..:F le.l umt of <br />102-20231823 <br />:1. DECEDENTS LEGAL: NAME (FIRST;MIDDLE..LASTSUEFIX) <br />03/I41.1.1 <br />8. CRY/TOWN, COUNTY AND ZIP OR LOCATION OF DEATH <br />PHOENIX, MARIGOPA;` 85028 <br />9 EACE OF DEATH (TYPE OFPLACE:'HEDEATH.AND FACILITYNAME/ADDRESS) <br />RESIDENCE'4'2835 E CAtstNUN DRIVE <br />10. BIRTHPLACE (CITY AND STATE OR FOREIGN COUNTRY}'"':' <br />THAI`SINH, VIETNAM . <br />13. DECEDENTS USUALRESIDENDE ADORESS.i9TREEi CtTS:i <br />2835 E CANNQ.N DRIVE,:P.HOENIX,:MARICOPA, AZ685028: <br />14. DECEDENTS HISPANIC ORIG1N(S): F: 'C ----::: 18. DECEDENT'S RACE(5k <br />VINH, CAO, NGUYEN <br />20. INFORMANT'S NAME (FIRST, MIDDLE, LAST, SUFFIX) <br />MARIE, , NGUYEN <br />.:.:22. INFORMANTS MA1LING:YIDDRESS <br />2835 E -CANNON DRIVE, PkoEistixiAZ 8 <br />23. NAME AND ADDRESS OF FUNERAL FACILITY ORRESPONSIF3LE PERSON <br />BEST FUNERAL SERVICES.- NORTH CENTRAI. CHAPEf: <br />501 EDUNLAP;AVENU `PHOENIX;-AZ,,85020 ! i <br />':;26. K1ETH00(SrOF OESP!OSRK)N 27.31AME ANDLDCATIONCE.411T. 109FOSITION£ <br />B..... KIN R4 BER. :: a. . <br />CREMA7 rON F EORIA US <br />'37. OTHER SIGNIFICANT CONDIT(ONS'C0NTRISUTING3ONEDEATH BUT NOTRESULTING IN TE' <br />UNDERLYING CAUSE GIVEN IN PART I:" - <br />39. BOURYA-r WOR.RK? ':F: Fi40..MANN ER°OF DEATH <br />tqAti)Rike Dekni <br />42. WAS AN AVI'OPS0 4.1wEREygt,[i'011MV FINDINGS ISV/11LA8LE <br />PERFORMED?,r. ' -TO,COMPLETETHE CAUSE OF DEATH? <br />`d1.0JAMEtlp.PERB0li:. NOCAL/S .S <br />TO THE BEST OF MY KNOWLEDGE, THE INFORMATION <br />"- <br />:...:::.:::... <br />ABOVE 1S CORRECT AND THE DEATH OCCURRED DUE <br />xC:THECAUSB:S)AN NNEREMED..;;;i;;: :.SAMANTHA, , RAMSAY <br />Th s rs a'ttsie cettlf,cattott of t#te#acts at..file` Kith the AdaST�fa tOepastn+enk of <br />Healtkt:Services BltreaaofVUAt'Re!oM0 AHOENIX, AR{ bNA rf <br />Revised"07/2016 .: A$ ISTAla $i$'al <br />TGis.copynotvalid unlessprepated on a form displaying the State Seal and impressetly tk'tSSe'taisStl seSSpf:the isswng;agenc• <br />1' 1,�Y'�IC�'+.M�SIrkN4.,a4:44'A'V',444/4.4.44'4 4MMY.1hf:1{'N; <br />ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATE? <br />r':. <br />ARIZONA' DEPARTM'ENT' <br />OF HEALTH SERVICES. <br />