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OFFICE of Vf L� ST'ATiSTICS
<br />- CERTWIED COPY
<br />20040'7459
<br />RI T °N CERTIFICATE OF DEATH
<br />RMANENT
<br />LACK INK LOCAL FILE NO. FLORIDA
<br />J1. ECEDENTS NAME FIRST MIDDLE LAST
<br />Eleanor R. Marget
<br />ATE OF DEATH (Month, Day, Year) 4. SOCIAL SECURITY NUMBER 5a. AGE -Last Birthday 5b. UNDER
<br />Jul 29 2002 485 -18 -9304 (years) 79 Months
<br />6. DATE OF BIRTH (Month, Day, Year) 7. BIRTHPLACE (City and State or Foreign Country)
<br />GIVE KIND OF
<br />WORK DONE
<br />DURING MOST
<br />OFINORKING
<br />U" NOT
<br />USE RETIRED.
<br />9a. PLACE OF DEATH (Check only one: see instructions on other side)
<br />■
<br />2. SEX
<br />Female
<br />YEAR Sc. UNDER 1 Da
<br />Days Hours I Minutes
<br />8. WAS DECEDENT EVER IN U.S.
<br />ARMED FORCES? (Yes or No)
<br />No
<br />9b. INSIDE CITY LIMITS? (Yes or No)
<br />HQSPLTA Inpatient _ ER/Outpatient _ DOA OTHER: _N rsing Home Residence _ Other S i
<br />9c. FACILITY NAME (If not institution, give street and number) 9d. CITY, TOWN, OR LOCATION OF DEATH 9e. COUNTY OF DEATH
<br />13116 Clermont Street Hudson Pasco
<br />10a. DECEDENTS USUAL OCCUPATION I 10b. KIND OF BUSINESSANDUSTRY 11. MARITAL STATUS - Married, 12. SURVIVING SPOUSE (17 wile, give maiden name)
<br />Never Married, Widowed,
<br />Homemaker Own Home Divorced (Specify)
<br />13a. RESIDENCE - STATE I 13b. COUNTY
<br />Florida Pasco
<br />Widowed
<br />13c. CITY, TOWN, OR LOCATION 13d. STREET AND NUMBER
<br />Hudson 13116 Clermont Street
<br />13e. INSIDE CITY 13f. ZIP CODE 14. WAS DECEDENT OF HISPANIC OR HAITIAN ORIGIN? 15. RACE - American Indian, 16. DECEDENTS EDUCATION
<br />LIMITS ?(Yes or*) (Specify No or Yes - rf yes, specify Haitian, Cuban, Black, While, etc. (Sped on (y highest grade con)pleter
<br />Mexican, Puerto Rican, etc.) X No _ Yes Specify White ElementarytSecondary I College (1 -4 or 5 +
<br />It No 34667 Specify.
<br />17. FATHER'S NAME (First, Middle, Last)
<br />Geor a Stash
<br />19a. INFORMANTS NAME (T ring
<br />Frank H. inder
<br />20a. METHOD OF DISPOSITION
<br />_ Burial X Cremation _ Removal from State
<br />Donation _ Other (Specify)
<br />ta.
<br />218. SIGNATURE OF FUNERAL SERVICE LICENSEE OR
<br />(0-12)
<br />18. MOTHER'S NAME (First, Middle, Maiden Sumame)
<br />Mary Hertle
<br />19b. MAILING ADDRESS (Street and Number or Rural Route Number, City or Town, State, Zip Code)
<br />2612 South 167th Circle. Omaha. Nebraska 68130
<br />20b. PLACE OF DISPOSITION (Name of cemetery, crematory, or 2Oc. LOCATION - City or Town, State
<br />other place)
<br />Southeastern Crematories Hudson, Florida
<br />21b. LICENSE NUMBER 21c. NAME AND ADDRESS OF FACILITY
<br />(of Licensee) Family Funeral Care
<br />'311? 13011 U. S. Hwy. 19, Hudson, Florida 34667
<br />22a. To the best of my knowledge, death occurred at the time, date and place and due
<br />to the cause(s) as stated.
<br />Signature and Title) to Aq ------- %
<br />22b. DATE SIGNED (Mo., D Y4 22c. HOUR OF DEATH
<br />�� 1 11:13 P.
<br />22d. NAME OF ATTENDING PHYSICIAN IF OTHER THAN CERTIFIER (Type or Print)
<br />24. NAME AND ADDRESS OF CERTIFIER (PHYSICIAN, MEDICAL EXAMINER) (Type or Print)
<br />�,¢ 23a. On the basis of examination and/or investigation, in my opinion death occurred
<br />Z at the time, date and place and due to the cause(s) and manner as stated.
<br />m (Signature and Title) ►
<br />Ew 23b. DATE SIGNED (Mo., Day, Y4 23c. HOUR OF DEATH
<br />U'�
<br />a M
<br />a C9 , 23d. MEDICAL EXAMINER'S CASE e
<br />rw
<br />f -- -
<br />25a. SUBREGISTRAR - SIGNATURE AND DATE 25b. REGISTRAR - SIG TUR . DATE REGISTERED
<br />► �pD o�
<br />26. PART I. Enter the diseases, injuries, or complications that caused the death. Do not enter the mode of dying, such as cardiac or respira arrest, shock A oximate Interval
<br />or heart failure. List only one cause on each line. Between Onset and
<br />Death
<br />IMMEDIATE CAUSE (Final
<br />disease or condition /
<br />resulting in death) --73;;- •1(f s�%�b CIRAI iglu t,/ / 04 74-k o1"V 1- ✓ '
<br />DUE TO (OR AS A CONSEQUENCE OR: I
<br />Sequentially list conditions,
<br />if any, leading to immediate
<br />cause. Enter UNDERLYING
<br />CAUSE (Disease or injury
<br />that Initiated events
<br />resulting in death) LAST
<br />b. I
<br />UUE TO (OR AS A CONSEQUENCE OF): '
<br />c.
<br />DUE TO (OR AS A CONSEQUENCE OF):
<br />\ d.
<br />PART II. Other significant conditions contributing to death but not resulting in the 27a. WAS AN AUTOPSY 27b. WERE AUTOPSY FINDINGS 28. CASE REPORTED
<br />underlying cause given in Part I. PERFORMED? USED TO COMPLETE CAUSE TO MEDICAL
<br />(Yes or No) OF DEATH? (Yes or No) EXAMINER,
<br />No No a SYes or No)
<br />29. IF FEMALE, WAS THERE A 30a. IF SURGERY IS MENTIONED IN PART I or II, ENTER CONDITION FOR WHICH IT WAS PERFORMED 30b, DATE OF SURGERY (Mo., Day, Year)
<br />PREGNANCY IN THE PAST
<br />3 MONTHS? Yes X No
<br />31. PROBABLE MANNER OF 32a. DATE OF INJURY I 32b. TIME OF 32c. INJURY AT WORK? 32d. DESCRIBE HOW INJURY OCCURRED
<br />DEATH (Specify) (Month, Day, Year) INJURY (Yes or No)
<br />Natural, accident, suicide,
<br />homicide, or undetermined.
<br />M
<br />512. 9/96 rN� �V tip
<br />)laces HRS
<br />n 512)
<br />AUG - 6 2002
<br />PLACE OF INJURY - At home, farm, 132f.
<br />street, factory, etc. (Specify)
<br />or Rural Route Number, City or town, State)
<br />THIS IS A CERTIFIED TRUE AND CORRECT COPY OF THE OFFICIAL RECORD ON FILE IN THIS OFFICE
<br />BY: • %' e
<br />State Registrar
<br />DSPQl'Y )itIaGIBT>i�A
<br />WARNING- OFTHE OSTATE OF FLORIDA. DO NOTOACCEPTIWITHOUT SECURITY
<br />ERIFYING THE PRESENCE OF THE WATERMARK. SEAL
<br />THE 2'6 T 9 3 , CONTAINS SPECIAL LINES WITH TEXT ND�SEALS IN THERAMOCHROMD INK, GOLD EMBOSSED SEAL THE BACK
<br />DOH FORM 1564A (9/99)
<br />
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