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Kansas Department of Health and Environmen 2 C
<br />Ofee of Vital Statisti
<br />•DEATh
<br />„.
<br />CERTifICATE OF
<br />State Pile Number 11 203 G.fl74
<br />Decedents Legal Name (s1,*t, iThkUe
<br />/07/1942 MALE 507-34 339
<br />_., Marital t
<br />iage
<br />Date of Death Age Uateofllirth Sex
<br />Social Security Number
<br />0112212023 80 VEAB(S)
<br />KANSAS 6402
<br />ST PAUL, • n/04 • •
<br />• ” , 09 „
<br />„„,
<br />State or Foreign Country Zip Code
<br />MANBAThN
<br />2!'
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<br />Pather/Parent Name Prior to Elrst Marriage
<br />rent Name Prior to First Marriage
<br />• - ..•„........•• -
<br />ACE) A ' - • •
<br />• - NETH
<br />• FsicillOi Name::
<br />VIA CEPJSII
<br />VILLAGE 280Q WILLOW GRQVE RD• , : .
<br />• •-• Zip -•
<br />Col!nty mL12Y 66502
<br />Place of Disposition • •••': • Location of Disposition.
<br />CARLSONGEISENDORF eftl*TO
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<br />ate Interval: •
<br />Onset
<br />•
<br />Date of Injury
<br />Place of Injury
<br />"• '••••••••"'
<br />InitOlsr Occurred
<br />1441 Certi°g DO 015621058 202304001174, 6
<br />01/25/2023
<br />01/21)2023
<br />RI
<br />Me41TIM0THY1W-Srsir; 0112112023 101 awls
<br />•
<br />oleo #-Y
<br />State Reis
<br />•
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