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LOCAL REGISTRAR <br />ATCHISON COUNTY HEALTH DEPT <br />421 MAIN <br />TARKIO MO 64491 <br />MINTER FUNERAL HOME <br />217 N MAIN <br />ROCK PORT MO 64482 <br />MISSOURI DEPARTMENT OF HEALTH <br />AND SENIOR SERVICES <br />FEE RECEIPT <br />DEATH CERTIFICATION <br />202404535 <br />REGISTRANT(S): <br />HECTOR J CARBAJAL <br />D9999-999999 <br />1 COPY <br />YOUR RECENT REQUEST HAS BEEN ACTED UPON AS INDICATED BELOW: <br />DATE RECEIVED <br />09/30/2020 <br />TOTAL AMOUNT <br />11.00 <br />AMOUNT THIS REQUEST <br />11.00 <br />PROCESSING FEE <br />REQUIRED 0.00 <br />REFUND <br />0.00 <br />MO 580-0698 (6-19) <br />UNAPPLIED REMITTANCES ONLY VALID FOR ONE YEAR AFTER RECEIPT. When you inquire about your request, <br />please return this receipt. If a refund is indicated, it will be mailed within 30 to 60 days. <br />!tiI1SS01. R1 <br />CERTIFICATION OF DEATH <br />DATE FILED: SEPTEMBER 29 , 2020 STATE FILE NUMBER: 124-20-031717 <br />DECEDENT NAME: HECTOR J CARBAJAL <br />DATE OF <br />DEATH: <br />SEPTEMBER 23, 2020 <br />DATE OF AUGUST 24 , 1971 <br />BIRTH: <br />SOCIAL <br />SECURITY NUMBER: <br />508-23-2994 <br />COUNTY <br />OF DEATH: <br />ATCHISON <br />MARITAL MARRIED <br />STATUS: <br />S•r <br />SEX: MALE <br />EVER IN <br />ARMED FORCES: NO <br />RESIDENCE 1322 SHERIDAN PLACE <br />ADDRESS: GRAND ISLAND, NEBRASKA <br />SURVIVING SPOUSE: RUTH MARTINEZ <br />FUME 8 AbRRAN FUNERAL CHAPEL <br />MANNER: ACCIDENT <br />BLeleRVe tUFaffinO HEAD AND NECK - IMMEDIATE <br />ISSUED ON BEHALF OF MO DEPT HEALTH & SENIOR SERVICES:ATCHISON <br />THIS ISA TRUE CERTIFICATION OF NAME AND DEATH FACTS AS RECORDED BY THE BUREAU OF VITAL ��RECORDS,JJEFFERSON CITY, MISSOUR`;`�F H,EALTf 6 • <br />y <br />SEPTEMBER 30, 2020 (d%rvrlit.rl . fa orkiV 4�,YY '+- �099 <br />DATE ISSUED: <br />Kenneth J. Palermo <br />State Registrar <br />o <br />'�. •+' -` , `� ,..'', THE REPRODUCTION OF THIS DOCUMENT IS PROHIBITED BY LAW. <br />ANY ALTERATION OR ERASURE VOIDS THIS CERTIFICATION. <br />'i,......................,..Ri..,..t,.....�.,....16861......................11,.,,Nfd..it......M.,....,........,......,.,......w.N..�ii.,�f3iifc..,. .. ... .. .:.. <br />,40 <br />