|
''t S ! STATE OF IOWA � � �C�
<br /> IOWA DEPARTMENT OF PUBLIC HEALTH v
<br /> • CERTIFICATE OF DEATH 114-
<br /> JTYPE gIRTH NU��'.BER �
<br /> IN pECcDENT'S . FIRST MIDOLE � LAST DATE OF QEATH r,Lfo_Day.Yr.)
<br /> PERMANENT niqME
<br /> °�F.cK'"K , Elsie S E. Lee 2. December 31, 1992
<br /> i!dSTa�RIOrvS �`� �GE-LAST BIRTHDAY UNCEA 1 YFAR UNDER 1 DAY .DATE CF BIRTH Ildo..Day. Yr./ COUNTY OF DEATH
<br /> SEE (�ears) , MOS. DAYS HRS. MIN.
<br /> H,�NOSOOK s. Fenale aa. 74 ,b. 4�. s�ov. 7, 1918 sa. Monona
<br /> FACILITY NAr,n,_�//�i���:�i;;i,(up��n ��v��bccl;uul numh�,y� Cll Y,TOWN.ON L.00�TION OF DEAI H INSIOE CITY UMITS
<br /> 6b. Pleasant View Nursing Home 6�, Whiting 6dpec1yVe$ "O'
<br /> y
<br /> 6e. P�ACE OF DEATH lCheck only oneJ
<br /> HOSPITAL OTHER �
<br /> ❑ Inpati?n; ❑ ER!Outpat��en; ❑ DOA �',Nur;ir.g Home ❑Resitlence ❑Other ISpecily)
<br /> � � VJP.S DCCEDENT OF HIS?AN!C ORIGIfJ? RACE-Whlte,Black. DECEDENT'S EDUCATION ISpecity only ivghest grade complered/
<br /> (Specify No o�Yes belo�r�) American Intlian,etc.(Specilyj
<br /> If yes,specity CuGan.Mexicar.Puerto Rlcan,eta ElementaryiSecondary(0-12)' Co�lege(1-4 or 5-)
<br /> USUALRESI- �� 1�VO ❑YF..S s;;��;ry� � s. � white 9. 12
<br /> DENCE WNERE BIRTHPLACE �
<br /> DECEDENT CITIZEN OF WHAT COUNTRY MARRIED.NEVER MARRiFD. SURVIVWG SPOUSE(if wifc,give rnaiden name)
<br /> LIVED,IF DEATH (Ciry F e o�For2��n Country� � WIDOWED,DIVORCEQ(S ecdy) �
<br /> OCCURREDINA ,o. S��oan, �Iowa ,,. U.S.A. ,Za. marrie� ,zb. Clifford Lee
<br /> LONG-TERM
<br /> riori,GrvE TV SCiCIA��cC''u^nIT':t;1;:.1E��°, ,;gUp.!n�r��oqT;O�'v(Gh•e kind ot wor'R�ione during most KINO OF BUSINESS OR WDUSTRY WAS DECEOENT EVER IN U,S.ARMED
<br /> wsnrunor+ o�workiny i�t� Do na use retired_) � oco�i!r�co i��ecily yes or no)
<br /> ��oRE55,,S ,3. 481-62-0855 ,Qa. `Iiomemaker-own home ,Qb. homemaker ;s`. no
<br /> RESIDENCE
<br /> � P.wi:iciSCE-dra.�= CivJidir C�T'r,�CYti�vvr,LvCA'IC'. — -- uTR€Ei,:.2DA ::BGF�G. F�S.^,ED'CE r.,,ci��r.����in�.�;�
<br /> lSpeci/y yes or no/
<br /> ,sa. Iowa ,sb.Woodbury ,e�. Sloan ,se. 320 Cedar t6e. 2S
<br /> FATHER'S FIRST � MIDULE LAST MOTHER'S FIRST MIDDI.E MAIDEN
<br /> NAME NAME
<br /> ,�. Peter --- Larson ,a. Minnie --- McDonald
<br /> �. IN�ORMANT'S MAILING ADDRESS(Sveet and Number or Rural Route Number,C�ty or Town.State.Zip Code)
<br /> NAME
<br /> ,e�. Clifford Lee (husband) ,9b. 320 Cedar, Sloan, Iowa 51055
<br /> Oa.METNOD OF DISPOS!TIGN P�ACE OF DISPOSITION�Name ol Cemetery.Crematory. LOCATION(City or Town.Stale)
<br /> � �un;l ❑Cremation or o;t�er place) �
<br /> ❑Femoval(POm Sta!e
<br /> ❑ oo������� ❑�o�r,��rs�->��ry� 20�. Fairview Twp. Cem. 20� Rural Sloan, Iowa
<br /> FUNER,=��DIH�'f0,9-jIGNATUFjE� F.D.�!CENSE x
<br /> � � ' f
<br /> �� ' �
<br /> 21a.� f, ' ( i'�'"\ �r: .� ,... ., .. � /: ,
<br /> ;i..-.�...:...�L,� ,,. / 7 .i'1��� ?�.t..i. i� �.__-:,.�--....._��� 21b. �
<br /> FUNEFFlL HOM�-NAME AND ADDRcSS(Str��t an�Number or Rural Rou�e Number,City or Town,State,Z�p CoCej
<br /> ,�Wood Funeral Home, 511 5th Street, Sloan, Iowa 51055
<br /> [GISTRAR-SiGNATI��tE , <.Fl,.� ,,,„- ; DATE RECEiVED BY REGISTRAR
<br /> 2a. . . ... . (MO..Day. Yr.l i':
<br /> � � 22b. ` � t '�t.Z
<br /> 23.Nr�.NNER O�DEA1�H DATE OF INJURI' HOUH GF INJURY INJURY AT`NORK? DESCRIBE HOW INJURY OCCURRED
<br /> (Pno..Cay. Yr./ (Specily yes or no)
<br /> �'Naturai ❑Pendir.g p4a. 24b. M. 24a 24d.
<br /> ❑Acciden� Investigation pLACE OF INJURY!Specily a;horne,farm.s�reet. LOCATION(Stree;anC Number or Fural Rou:e Number.G(y or Town.State.Z�p Code)
<br /> ❑Suicide ❑ CowC not be �2ctory,oftice bwlding,etc.j
<br /> ❑Horr,icide tletermined ?4e �� 24f . .
<br /> To the bast of my knowleCye,deatn occurre �:;(�e tim� �ate ard plac du@ lo thq cause(s',*n�manner as st2ted. DATE SIGNED(fdo..Day. Yr./ HOUR OF DEATH
<br /> \ " ,�
<br /> 25a.(Signature and titie)P � �, ;,�, � y?, f��;�;_ :,% ��!� �0, � /�� zsb. 1-13-93 ss�.7:lSam M
<br /> NAME AND TITLc OF ATTEND NG PHYSICIAN If THER THAN C RTIFIER!Type/PrinO � �
<br /> - 26. "
<br /> NA AE ANL�ADDR65S;.r l F;il li- ��ny�;�r�. . .. t;i_�I =s:;�miner)(TYPe/Print`.
<br /> z�. J. L. Garred, Sr. , M:D. 153 Blair Street itir.7itin�, Iowa 51G63
<br /> 28.PART I. Enter!he diseases.injuries.or complications;hat caused the death.Do not enter the mode of dying,such as cardiac or respiratory arresL - � Approximate
<br /> shock,or hearl ta:l�,re.Lis;or•,ly one caose on each lir.e. � � Interval 9etween
<br /> � Gnset and Death
<br /> I
<br /> Final disease or condltion------a- I�'vIPdEDINTC CHUSE � �
<br /> �`s`'�;��5,;'d`?`h Metastatic adenocarcinoma lun�__ ; 6 months
<br /> ��� - --- _�
<br /> D'JE TO(OR N;i A CONSEOUL=NCE OF)� I
<br /> � ' Primar carcinoma of colon ; 1 year
<br /> � SeGuenlially li;t conCiiions.�I any, ��� _ _ y
<br /> ieading to imm�d�a;a canse.Er.ter DUE TO(OR AS A i'ONSEQUFNCE OF)_.
<br /> UNDERLYING CAUSE(Dise2se or � . �
<br /> inj�fy thal irn;iat@d P.ven(S resulting jC) I
<br /> in ceathl LAST. DUE TO(OR AS A CONScOUENCE OFj�. �
<br /> �°� - -- --- 1
<br /> PAH'Ii.a. O;her siGri'icant cordi;�o❑s con;nbu[�r.y:�;�:'ea;:�but not;esull�ng in ihe � b.IF FEMALE.WAS THERE A AUTOPSY WERE AUTGPSY FIND-
<br /> und�rlying causes g�wen in P,=.r,I. � PREGNANCY IN THE PAST 12 /Specily yes or nol INGS AVAILABLc PRIOR
<br /> . � MONTHS? TO COMPLETION OF
<br /> CFN-582-OC21 � (Specily yes or no) CAUSE OF DEATH�
<br /> � /Spec�ly yes or no)
<br />,9ev'�sed-i/ss � N� 2sa. N� 29b.
<br /> _..�_�....._................__.._.____,_ .__..._--
<br /> ---- ---_.__. . ____
<br /> 1 -
<br /> T HEREBY CERTIFY that the above information is on file in the office of the �'lerk �
<br /> � � �
<br /> of Cuurt i.n accordance with the law of Iowa requiring the filing of Vital Rec�rds .
<br /> Recorded in: Boo�c, h Page 225 D�te January 19, 1°93
<br /> ._ '_ ., `_^�+..o �cac������
<br /> County Registrar & C1erk of District Court
<br /> (Sr.AT) - SUE HANSOHN
<br /> . �, � � �
<br /> � Y
<br /> � 1. • BY—_ `:�C�C�������
<br /> - Deputy C�e,�k
<br />
|