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11111 <br />1. FULL NAME OF DEICED <br />NANA <br />2. SEX <br />MALE <br />6. WAS <br />Ill <br />u11 <br />54719 <br />❑ <br />(tint) <br />VERIFY PRESENCE OF WATERMARK HOLD TO LIGHT TO VIEW <br />OMMO <br />'1 DEPARTMEP <br />II 11llp ll„� <br />COMMON l <br />DEPARTMET <br />3. DATE OF DEAIR <br />JAN <br />YGCII II��ENF EVER IN U.S. ARMED FORCES? <br />YES NO INRNOWN <br />0 ❑ <br />I1,' 2025 <br />ALTH <br />%1LTH - OFFII <br />„1 <br />IITH OF VIRGINI <br />ALTH - DIVISIO CRC'', <br />ACTUAL <br />7. BIRTHPLACE (11.8 STA <br />NEBRASKA <br />9. STREET ADDRESS (INCLUDE HOUSE AND/OR APT. NOR ROUTE NO.) <br />800 SOUTI,ISAINT ASAPH ST APT$II <br />Il. COUP? <br />11 <br />D <br />RESIDENCE (if independent <br />11111 <br />%Ilp� EDENT (CHECK ONE OR <br />❑ BLACK 081 <br />J 9 IAN INDIAN ❑CHINESE III <br />❑ NATIVE HAWAIIAN ❑GUAMANIANOR ICHAMORRO <br />14. DECEDENT OF HISPANIC ORIGIN? <br />ICI NON -HISPANIC n CENTR <br />15. EDUCATION (MGHE <br />16. CITIZEN <br />19. <br />NE <br />❑ F1UPINO ❑ I 111 <br />�, ❑ OTHER PACIFIC <br />❑ SAMOAN ❑ VI MINE ❑ OTHER ASIAN ISPBCJF <br />❑ JAPANESE ❑UNKNOWN ❑ OTTER (SPECIFY) <br />Omddle <br />FOUND <br />DON COUNTRY) <br />I11 <br />I, <br />1101 <br />�! I , ERGINIA <br />VMTAL RECORDS LIII <br />RTIFICATE OF DEA <br />INN <br />AL RECORDS - RICHMO <br />STAL <br />DATE OF BIRTH iI <br />JULY <br />10. CITY OR TOWN OF RESIDENCE <br />ALEXANDRIA <br />11 US. STA <br />VIRGI <br />OR SOUTH AMERICAN <br />.FOMPLETED) <br />BACHELOR'S DEGREE <br />411 <br />S" <br />Y, <br />hi, AMERICAN INDIAN OR <br />kONDARY (0-12) <br />ES <br />17. USUAL <br />MAN <br />a? `R LED ❑ MARRIED ❑ WIDOWED © DIVORCED ❑ SEPARATE <br />21. 21. FULL NAME OF DECEDENTS FATHER OR PARENT E(DM.middle3at.afa1naiden ame.if any) <br />HARRY CLYMO STALKER <br />23. INF <br />SIS7 <br />IH <br />7IONSHIP OR SOURCE OF INFORMS. <br />ITAL OR INSTITUTION OF D <br />A FAIRFAX HOS11 <br />Ec1FY D' DEATH OCCURRED <br />HOSPICE FACILITY ❑NURSING <br />27. CITY OR TOWN OF DEA <br />FALLS CHURCH N,I <br />29. METHOD OF DISPO <br />BUII 1 <br />RIAL <br />❑ BURIAL AT�'i' <br />❑ REMOV <br />3ME <br />11 MI <br />OTHER THAN A HOSPITAL <br />❑ MEXICAN ❑ PUERTORICAN <br />11'I,I, <br />UNKNOWN <br />21. GENDER <br />►LE <br />IIII <br />(OR 1j <br />ra�I <br />IIIII <br />DATU C0RD1ji.ED <br />JANUARY 15, 2025 <br />11111111 <br />.AGE <br />Yeas <br />67 <br />BECUIUTINUMBER <br />507-62-2327 <br />Y)0P DBCEDRNIS <br />1111 <br />0 <br />,1111 <br />ll <br />II <br />II <br />1,11111 <br />tr <br />2507 <br />V1I1111I <br />STA1SP1Z'F <br />NOTOBT <br />.INE4DR.CTFYORT(! <br />Ijiil' u, <br />2► <br />22314 <br />1 DAY <br />utl <br />1 <br />I0 <br />❑ OTHER (SPECIFY) ,IIII; <br />HIGH SCHOOL DIPLOMA <br />❑ DOCfORATFJPROFESSI3 <br />ON <br />ANALYST <br />20. IF MARRIED, SEP <br />Eli <br />EbIJ.III 1' ❑UNKNOWN ❑ <br />18. <br />(WIDOWED. NAME OF SPOU <br />22. FULL NAME OF DECEDENTS MOTHER OE PARENT 1( <br />PATRICIA Lh1U PARSONS <br />24. FULL NAME <br />DACIA <br />❑ LONG TERM CARE FACILITY ❑ DECEDENTS HOME ❑ CORRECTIONAL FACIL <br />28. STREET ADDRESS OR RT. NO OF PLACE OF DEA <br />3300 G. <br />DSN'OMBRffiNf MA <br />❑ DONATION <br />TE WN PLEASE ALSO <br />SFOSITION -NAME OP CEMH'IEAY OR <br />OLITAN CREMATORY <br />31. PLACE OF DISPOSITION -STREET ADDRESS OF CEMB <br />5517 VINE STREET <br />32. SIGNATURE <br />/S/ <br />U SEE. VSAP <br />NDLE <br />33. N,�;',pP ll DIRECTOR/LICENSEE. <br />`ItENDLE <br />34 ° i,i OFDEATH: Tothe beat *thy <br />PART 1. Bmer the diaaam, <br />(SPECIFY) <br />a�lmJ+,r <br />R CREMATORY <br />A <br />. 04:5 <br />RIA <br />FR <br />ACTUAL <br />31b. STA <br />VIR <br />coed the death. Do nol enter the mode ofdyinS, such a cardiac or rapintoryarrest, shock a han hi <br />IMMEDIATE CAUSE OFDEATH <br />(Final &iaaaorcondition resulting inhash) (A) ACUTE CARDIAC "� T <br />TO( AI 4&QUW4CE on <br />(10) ASPIRAT�IMONIA <br />JO u��++L <br />JE el'-ONBBQU@JCE OF) <br />CE d �V7liSCULAR DISEAI S <br />1111 6, " (OR AS A CONSEQUENCE OP i1 1 <br />Sequentially list conditions, <br />to immediate cause.E <br />CAUSE (Disease a l <br />ooWI ng in death A1r;lli111,1 <br />(C) <br />(D) <br />INN <br />II <br />OR NAME OP SOURCE <br />OTHER (SPECIFY) <br />Il <br />Zee. ZIP <br />rl <br />!lu <br />2 <br />IN] <br />231. S <br />MHO <br />Mukha <br />1111 <br />14 N11 <br />'I lli!II <br />�i!!I <br />T} <br />OUTPA <br />EMIR <br />28k COMM of OBAti6riadtpalwt <br />FAIRFAX COUNTY <br />10 <br />gII <br />1IaIIIIIIl <br />111i( ` <br />IIII' <br />31 <br />lil <br />DA <br />) <br />MALE <br />1111 <br />IIII <br />PART 11. Other significant conditions *attributing to dell but not re,n iog in the underlying cause given in Part I. <br />36. WAS <br />hF'*ENV� YE9 ONO II <br />1 <br />p1t ANT AT TIME OF DEATH IIIi II UNKNOWN IF FREON <br />PREGNANT WTrtIIN PAST YE 1111111li, III. ❑ NOT PREGNANT, BUT <br />EXTERNAL, TO WHAT EXTENT IT CUTTID TO CAUSE OF DEATH? <br />❑ PRIMARY ❑ CONTRIBUTING <br />EIXAMINER CONTACTED? 1111 <br />'C AI UYHTJ <br />III[j YES <br />Ili <br />AVAILABLE TO CO <br />❑ VHS I <br />PAS[YEAR <br />IIT IN 43 DAYS TO 'YEAR BBP I <br />7. <br />Omar PRi(RiAN'r, WE <br />❑NOTAPPUCABLE (1) <br />D742DAYRQ <br />or 75 Tam) <br />la <br />40. WAS THIS A MILITARY DEATH? <br />❑ YES O NO <br />Ma. W MILITARY DEATH, SELECT MANNER <br />NATURAL ACCIDENT SUICIDE <br />mums <br />47 IN THIS SECTION SHOULD <br />Y DE COMPLETED INOIIRIIIdTALIY D <br />1100010 <br />41. DATE OF INJURY <br />11 <br />45. L0CATIO19'I?&O I.1R <br />46.1E <br />V' li <br />42. TIME OP INJURY 111111111 <br />II„ <br />ET ADDRESS pRCGUD6nouns <br />A <br />TAME INJURY. SPECIFY <br />47. DESCRIBE e " INJURY RELATING TO DEATH OCCURRED <br />48. SIGNATURE <br />111 <br />COMPLETING THE CAUSE OF <br />.1( PROVIDING THE MEDICA... <br />PERATOR <br />YES Ej NO <br />IDE THE NA OF AU1140/kl. <br />This is to certify <br />Of Health, IR! <br />DATE I ES <br />Do not Pt unless on security pa <br />Section 32.1-272, Code of Virginia, as a <br />43. INJURY AT WOEK? 1 <br />YES ❑K <br />45a. CITY <br />/qpY <br />IIIII <br />UNKNOWN <br />6l ❑ <br />PEDESTRIAN <br />45b. STATE <br />MEDICAL DOCTDR <br />NURSE mucTrnoil <br />SS OP PERSON <br />AIRVIENV <br />a 14 ENT PHYSICIAN <br />111111111111 <br />M. Pt.ACE OF <br />CAL <br />TE <br />01 <br />btij Iii111it true and correct rag <br />the seal of Virginia Departm <br />nded. <br />11 <br />111 <br />le. ADDRESS OF AUTHORIZING PHYSICIAN] <br />n or abstract of the <br />111 <br />filed i Virgin <br />alth, Vital Statistics irt11 <br />left hand cOmer. <br />VS 15C <br />IN II <br />11 <br />